<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_441"
                     title="Be Ready for Drug-Induced Vfib, Groups Urge (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Cardiology/Arrhythmias/tb/18358?impressionId=1265782426143"
                     
      Awareness of medication-induced torsade de pointes and a preset protocol for treating it could save lives in the hospital with swift action to prevent cardiac arrest, according to a joint statement from two professional associations.&lt;br&gt;
&lt;br&gt;These cases &quot;should be avoidable&quot; with consistent electrocardiographic monitoring of patients receiving drugs known to prolong the QT interval, the American Heart Association and American College of Cardiology wrote in a statement endorsed by the American Association of Critical-Care Nurses.&lt;br&gt;
&lt;br&gt;The rare arrhythmia often provides telltale signs on ECG an hour or so before ventricular fibrillation, according to writing committee chair Barbara J. Drew, RN, PhD, of the University of California San Francisco, and colleagues.&lt;/p&gt;
&lt;p&gt;However, the statement made no one-size-fits-all recommendation on what cardiac monitoring should entail, given hospital-to-hospital differences in equipment that range from fully automated QT-monitoring systems at the high end to a computer-assisted electronic caliper feature at the other.&lt;/p&gt;
&lt;p&gt;&quot;Of utmost importance, however, is that a hospital protocol be established so that a single consistent method is used by all healthcare professionals charged with the responsibility for cardiac monitoring,&quot; Drew&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;This protocol should stipulate which equipment to use for QT measurement, how to determine the end of the T wave, the formula for heart rate correction, lead-selection criteria, and the importance of measuring the same lead in the same patient over time, they said.&lt;/p&gt;
&lt;p&gt;The new statement, published online in &lt;em&gt;Circulation: Journal of the American Heart Association&lt;/em&gt; and the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;, included the following signs of impending torsade de pointes: &lt;ul&gt; &lt;li&gt;An increase of 60 ms in heart-rate&amp;#8211;corrected QT interval (QTc) from the preadministration baseline&lt;/li&gt; &lt;li&gt;Marked QTc interval prolongation of more than 500 ms&lt;/li&gt; &lt;li&gt;The characteristic &quot;twisting&quot; of the points on ECG as T-U wave distortion becomes more exaggerated in the beat after a pause&lt;/li&gt; &lt;li&gt;Visible (macroscopic) T-wave alternans&lt;/li&gt; &lt;li&gt;New-onset ventricular ectopy&lt;/li&gt; &lt;li&gt;Couplets and &lt;span&gt;nonsustained&lt;/span&gt; polymorphic ventricular tachycardia initiated in the beat after a pause&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Prompt recognition of these ECG harbingers allows for treatment with intravenous magnesium, removal of the drug that induced the condition, and correction of electrolyte abnormalities and other exacerbating factors, including the prevention of bradycardia and long pauses with temporary pacing if necessary, according to the new statement.&lt;/p&gt;
&lt;p&gt;Prior guidelines on ventricular arrhythmias provided little help with prevention of torsade de pointes in the hospital but did recommend discontinuation of whatever drug induced long QT syndrome.&lt;/p&gt;
&lt;p&gt;The most common drugs associated with this potentially fatal arrhythmia are antibiotics, antipsychotics, and antiarrhythmia drugs.&lt;/p&gt;
&lt;p&gt;Administration in the hospital is more likely to be associated with torsade de pointes than is treatment of an outpatient population with the same drug, Drew&apos;s group noted.&lt;/p&gt;
&lt;p&gt;Hospitalized patients are often elderly, with comorbidities such as underlying heart disease and renal or hepatic dysfunction. They are also more likely to get intravenous push of the drugs.&lt;/p&gt;
&lt;p&gt;Clinical risk factors for torsade de pointes include: &lt;ul&gt; &lt;li&gt;A preexisting long QTc interval of more than 500 ms&lt;/li&gt; &lt;li&gt;Concurrent use of more than one QT-prolonging drug&lt;/li&gt; &lt;li&gt;Rapid infusion of a QT-prolonging drug intravenously&lt;/li&gt; &lt;li&gt;Heart disease, such as MI or heart failure&lt;/li&gt; &lt;li&gt;Advanced age&lt;/li&gt; &lt;li&gt;Female sex&lt;/li&gt; &lt;li&gt;Hypokalemia&lt;/li&gt; &lt;li&gt;Hypomagnesemia&lt;/li&gt; &lt;li&gt;Hypocalcemia&lt;/li&gt; &lt;li&gt;Treatment with diuretics&lt;/li&gt; &lt;li&gt;Impaired hepatic drug metabolism, whether from hepatic dysfunction or drug-drug interactions&lt;/li&gt; &lt;li&gt;Bradycardia&lt;/li&gt; &lt;/ul&gt;&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;Drew reported conflicts of interest with GE Healthcare and Philips.&lt;/p&gt;&lt;p&gt;Co-authors reported conflicts of interest with Medtronic, Pfizer, PGxHealth, FAMILION, GE HealthCare, Philips Healthcare, Abbott, Bristol-Myers Squibb, sanofi-aventis, Schering Plough, Inovise, Siloam, ArgiNOx, Astellas, Daiichi Sankyo/Lilly, Heartscape Technologies, Biosite, Inovise, Medicines Co., Millennium Pharmaceuticals, PDL BioPharma, Roche Diagnostics, Scios, Mortara Instrument, Cardiac Science, MDS Pharma, Medicure, St. Jude, Adolor, ARCA, AstraZeneca, Avanir, Cardiome, CardioDx, Novartis, Ortho Diagnostics, Sanofi, Vanderbilt/Clinical Data, iCardiac Technologies, LipoScience, Anthera, Abbott Vascular, Novo Nordisk, Roche, Biotronic, and Boston Scientific.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_387"
                     title="Canadian Politician Comes to U.S. for Heart Surgery"
                     score="0.011"
                     href="http://www.medpagetoday.com/Cardiology/AcuteCoronarySyndrome/tb/18279?impressionId=1265782426143"
                     
      &lt;p&gt;It is rare that a simple matter of patient choice causes an international flap.&lt;/p&gt;
&lt;p&gt;But that&apos;s what happened when 60-year-old Danny Williams of St. John&apos;s, Newfoundland, decided to go to the U.S. for heart surgery.&lt;/p&gt;
&lt;p&gt;That&apos;s because Williams isn&apos;t just any old Newfoundlander  --  he&apos;s the premier of Canada&apos;s easternmost province, the head of its government.&lt;/p&gt;
&lt;p&gt;The disclosure Tuesday that Williams was in an undisclosed location in the U.S., having an undisclosed procedure that he couldn&apos;t get in Newfoundland, brought catcalls from both sides of the border.&lt;/p&gt;
&lt;p&gt;The &lt;em&gt;New York Post&lt;/em&gt;, for instance, in an article headlined &quot;Oh (no), Canada&quot; used the news to take a whack at healthcare reform in the U.S. And the American Thinker blog  --  among many others  --  argued that Williams&apos; choice is evidence of the inferiority of Canada&apos;s &quot;technologically second-rate and rationed system.&quot;&lt;/p&gt;
&lt;p&gt;In Canada, cardiac specialists defended the premier&apos;s decision as a matter of choice and at the same time noted that  --  with few exceptions  --  most cardiac procedures are both available and done well in Canada.&lt;/p&gt;
&lt;p&gt;On the other hand, Newfoundland  --  with a population of about 500,000, less than Wyoming  --  is less well equipped. Doctors in the province do coronary artery bypass grafts (CABG) and other common procedures, but often send patients elsewhere in the country for transplants or rare operations.&lt;/p&gt;
&lt;p&gt;By way of contrast, doctors in Ontario  --  Canada&apos;s most populous province  --  handle more than 11,000 cardiac procedures a year in 11 specialized cardiac centers, according to Kori Kingsbury, CEO of Ontario&apos;s Cardiac Care Network.&lt;/p&gt;
&lt;p&gt;It&apos;s one of the places a Newfoundland patient might go if appropriate care wasn&apos;t available in that province, but Kingsbury said most of those 11,000-odd procedures are, in fact, performed on Ontario residents.&lt;/p&gt;
&lt;p&gt;Still, a &quot;handful&quot; of Ontario patients go to the U.S. every year for surgery, usually because they need emergency treatment and live close to the border, she told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;And every year, a few Americans cross the border the other way seeking care, she said, although she did not immediately have exact numbers.&lt;/p&gt;
&lt;p&gt;But for the most part, any required surgery can be obtained in a timely fashion in the province, Kingsbury said. In December, for instance, the median wait time for an elective isolated CABG was 14 days and urgent or emergency care was performed much more quickly.&lt;/p&gt;
&lt;p&gt;The exceptions to that rule are rare, complex procedures the experts in which reside in the U.S., according to cardiac surgeon Chris Feindel, MD, of Toronto&apos;s University Health Network.&lt;/p&gt;
&lt;p&gt;But the only nonexperimental example he can think of is repair of a rare aneurysm in the descending aorta, where the best care for the procedure is at Baylor University in Texas, Feindel told reporters.&lt;/p&gt;
&lt;p&gt;Because the condition is so rare, &quot;there&apos;s really no center across the country that has a large experience with these,&quot; he told the Canadian Press.&lt;/p&gt;
&lt;p&gt;In general, though, top-level cardiac care is readily available, according to Robert Roberts, MD, president of the University of Ottawa Heart Institute in the nation&apos;s capital.&lt;/p&gt;
&lt;p&gt;Roberts, who was head of cardiology at Baylor for 23 years before moving to Canada five years ago, said 99% of what can be done in the U.S. is done both routinely and well at his center.&lt;/p&gt;
&lt;p&gt;Premier Williams&apos; decision may have been influenced by the knowledge that Newfoundland does not fare as well as the rest of the country in some cardiac outcomes.&lt;/p&gt;
&lt;p&gt;According to the Canadian Institute for Health Information, the province has the highest rate of acute myocardial infarction, at 351 per 100,000 patients in 2007-2008.&lt;/p&gt;
&lt;p&gt;More revealing is the unplanned hospital readmission rate after a heart attack, which is regarded as a measure of quality of care. In 2007-2008, 6.2% of Newfoundland patients were readmitted, significantly higher than the national rate of 5.2%.&lt;/p&gt;
&lt;p&gt;And 30-day inhospital mortality  --  another marker of care quality  --  is also higher than the national average at 10.9% compared with 9.4%, the institute said.&lt;/p&gt;
&lt;p&gt;Kathy Dunderdale, the province&apos;s deputy premier, told reporters that Williams made the decision after weeks of consultation with his doctors and is expected make a full recovery.&lt;/p&gt;
&lt;p&gt;But she would not comment on his location or what procedure he needed, saying only that he could not get the care he needed in the province.&lt;/p&gt;
&lt;p&gt;A spokesman for the local health authority did not return telephone calls asking what procedures are not available in the province.&lt;/p&gt;
&lt;p&gt;Dunderdale also did not comment on who will pay for the surgery. Usually, if it&apos;s deemed medically necessary for a patient to travel outside the province for care, the taxpayer-funded medicare system picks up the tab.&lt;/p&gt;
&lt;p&gt;But Williams  --  sometimes known as &quot;Danny Millions&quot;  --  is personally wealthy, having made a fortune in cable television.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.01"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265782426143"
                     
      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_323"
                     title="Peptide Predicts Heart Failure in Older Patients (CME/CE)"
                     score="0.006"
                     href="http://www.medpagetoday.com/Cardiology/CHF/tb/18193?impressionId=1265782426143"
                     
      &lt;p&gt;Serial measurement of a natriuretic peptide predicted the risk of heart failure and cardiovascular death in older patients who were initially free of heart failure, data from a longitudinal cohort study showed.&lt;/p&gt;
&lt;p&gt;An increase of more than 25% in levels of N-terminal pro-B type natriuretic peptide (NT-proBNP) doubled the risk of heart failure and cardiovascular death. In contrast, a more than 25% decrease in NT-proBNP was associated with a greater than 40% reduction in the risk of both end points.&lt;/p&gt;
&lt;p&gt;&quot;NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk,&quot; Christopher R. deFilippi, MD, of the University of Maryland in Baltimore, and co-authors concluded in an article in the Feb. 2 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This change in [NT-proBNP] level reflects a significant change in patient risk independent of cardiovascular risk factors, ejection fraction, or medication use,&quot; they added. &quot;Ultimately, NT-proBNP levels may guide further diagnostic testing or potential preventive measures to reduce the risk of developing heart failure or dying of cardiovascular disease.&quot;&lt;/p&gt;
&lt;p&gt;About 80% of cardiovascular deaths occur in older adults. Assessing cardiovascular risk in older patients is challenging because traditional cardiovascular risk factors are less predictive in older versus middle-age populations, the authors wrote.&lt;/p&gt;
&lt;p&gt;Subclinical cardiovascular disease is common among older adults and increases the risk of cardiovascular events, including heart failure. Repeated measures of traditional markers of cardiovascular disease in patients with subclinical disease are associated with increased risk compared with patients who remain free of identifiable disease, the authors continued.&lt;/p&gt;
&lt;p&gt;Levels of BNP and NT-proBNP are associated with long-term cardiovascular outcomes in the general population. However, the peptides&apos; ability to provide additional prognostic information beyond that of traditional risk factors remained controversial.&lt;/p&gt;
&lt;p&gt;To examine the prognostic value of NT-proBNP in an older population, deFilippi and colleagues analyzed data on 3,000 participants in the Cardiovascular Health Study. The authors hypothesized that NT-proBNP levels in an ambulatory population of older patients would independently predict new-onset heart failure and cardiovascular death.&lt;/p&gt;
&lt;p&gt;&quot;Furthermore, we anticipated that serial measurements of NT-proBNP, as a possible surrogate for change in subclinical disease status, identify a dynamic change in long-term risk of incident heart failure and cardiovascular mortality,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Stored serum samples obtained at enrollment and two to three years later were used to measure NT-proBNP levels. Median follow-up for the cohort was 11.9 years.&lt;/p&gt;
&lt;p&gt;After separating the study group into quintiles of NT-proBNP levels, investigators found that patients with the highest baseline levels of the peptide (&amp;gt;267.7 pg/mL) had a threefold greater risk of new-onset heart failure (HR 3.05, 95% CI 2.46 to 3.78) and cardiovascular death (HR 3.02, 95% CI 2.36 to 3.86) compared with patients in the lowest NT-proBNP quintile (&amp;lt;47.5 pg/mL).&lt;/p&gt;
&lt;p&gt;The researchers identified 190 pg/mL as the NT-proBNP threshold for increased risk. Among study participants with baseline levels less than 190 pg/mL, an increase greater than 25% to a level above 190 pg/mL had a twofold increased risk of heart failure (HR 2.13, 95% CI 1.68 to 2.71) and cardiovascular death (HR 1.91, 95% CI 1.43 to 2.53) compared with participants whose NT-proBNP levels remained below 190 pg/mL.&lt;/p&gt;
&lt;p&gt;Among study participants with elevated baseline NT-proBNP levels, an increase greater than 25% also doubled the risk of heart failure (HR 2.06, 95% CI 1.56 to 2.72) and cardiovascular disease (HR 1.88, 95% CI 1.37 to 2.57).&lt;/p&gt;
&lt;p&gt;A decrease greater than 25% from baseline significantly reduced the risk of heart failure (HR 0.58, 95% CI 0.36 to 0.93) and cardiovascular death (HR 0.57, 95% CI 0.32 to 1.01) compared with participants whose baseline levels remained elevated.&lt;/p&gt;
&lt;p&gt;The investigators noted limitations of the study including the fact that a quarter of the participants did not have a follow-up blood sample and those who did were younger and had fewer cardiac risk factors.&lt;/p&gt;
&lt;p&gt;In addition, the length of follow-up could not account for differences in treatment over time, and the accuracy of NT-proBNP levels in samples as much as 20 years old cannot be assured.&lt;/p&gt;
&lt;p&gt;The study is noteworthy for highlighting the concept of dynamic risk assessment based on serial measurement of NT-proBNP, Richard W. Troughton, MB ChB, PhD, Matthew G. Daly, MB ChB, and Christopher M. Frampton, PhD, of the University of Otago in Christchurch, New Zealand, wrote in an editorial.&lt;/p&gt;
&lt;p&gt;&quot;The findings confirm a modest improvement in risk stratification by including a single measurement of NT-proBNP levels,&quot; they wrote &quot;The investigators take this a step further by showing that serial NT-proBNP measurement at a later time provides a further modest improvement in risk stratification.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Whether the improvement in risk stratification achieved by performing serial NT-proBNP testing crosses a threshold of definite clinical value needs further evaluation, with particular consideration of the cost-effectiveness of such a strategy,&quot; they added.&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 the National Institutes of Health, University of Pittsburgh, and Roche Diagnostics.&lt;/p&gt;&lt;p&gt;DeFilippi disclosed relationships with Siemens, Roche Diagnostics, BG Medicine, and Critical Diagnostics. Co-author Robert H. Christenson disclosed relationships with Roche Diagnostics, Siemens Healthcare Diagnostics, and Response Biomedical. Co-author Stephen L. Seliger disclosed a relationship with Roche.&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="-0.002"
                     href="http://www.medpagetoday.com/Cardiology/Prevention/tb/18075?impressionId=1265782426143"
                     
      &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;
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