Saturday, December 14, 2013

Diabetes Drugs Affect Men’s and Women’s Hearts Differently

Metformin had a favorable effect on cardiac metabolism in women but an unfavorable one in men, according to a study of 78 patients with type 2 diabetes. Adding rosiglitazone mitigated some of the negative effects of metformin in men, and improved heart metabolism further in women. Adding Lovaza (an omega-3 fish oil) improved diastolic function, particularly in men. The American Journal of Physiology – Heart and Circulatory Physiology studyused PET, echocardiography, and whole body tracer studies before and 3 months after randomization to metformin, metformin + rosiglitazone, or metformin + Lovaza.

Cisplatin Linked to Increased Acute Kidney Injury Risk

A study of 1721 Japanese cancer patients treated with cisplatin as a first-line chemotherapy between 2006 and 2012 found that cisplatin dosages/m² or diagnosis of stage 4 cancer were risk factors of moderate cisplatin-induced acute kidney injury (AKI). Patients with a history of diabetes, a history of cardiovascular disease, or a diagnosis of stage 4 cancer were risk factors for severe cisplatin-induced AKI. The Oncology study investigators note that because severe cisplatin-induced AKI can shorten survival, physicians should carefully consider whether the use of cisplatin will benefit patients with these risk factors.

Study finds CPAP may lead to reduced blood pressure in patients with sleep apnea and high blood pressure.

HealthDay (12/11, Reinberg) reports on a study published in the Journal of the American Medical Association finding that the treating of sleep apnea with the standard treatment of continuous positive airway pressure for 12 weeks led to reduced diastolic blood pressure and improved “overall nighttime blood pressure” among patients with sleep apnea who were “taking three or more drugs to lower their blood pressure.” Researchers recommended that patients with hard-to-control high blood pressure be tested for sleep apnea. The study covered 194 patients randomly assigned to CPAP or no CPAP. Those assigned to CPAP “lowered their 24-hour average blood pressure 3.1 mm Hg more than those not receiving CPAP,” and also had “a 3.2 mm Hg greater reduction in 24-hour average diastolic blood pressure.”

        Medscape (12/11, O'Riordan) reports the study found “significant improvements in their 24-hour mean and diastolic blood pressures, but no change in their systolic blood pressure.”

Study finds increased risk of B12 deficiency among long-term users of PPIs, H2RAs.

The New York Times (12/10, Saint Louis) reports on a study published in the Journal of the American Medical Association and conducted by researchers at Kaiser Permanente finding that proton-pump inhibitors and histamine 2 receptor antagonists “increase the risk of vitamin B12 deficiency.” That applies particularly to those patients who use the medications for two years or more. The study’s senior author Dr. Douglas A. Corley commented, “This raises the question of whether people taking these medications for long periods should be screened for vitamin B12 deficiency.” The study was based on the medical records of 25,956 adults diagnosed with vitamin B12 deficiency and 184,199 patients who did not have B12 deficiency during the period 1997-2011. Specifically, those “who took P.P.I’s for more than two years were 65 percent more likely to have a vitamin B12 deficiency” as 12 percent of those with B12 deficiency “had used P.P.I.’s for two years or more,” compared to “7.2 percent of control patients,” while 4.2 percent were “long-term” users of H2RA’s compared to “3.2 percent of nonusers.”

        The San Francisco Chronicle (12/11, Colliver) explains that B-12 deficiency is associated with greater “risk of dementia, nerve damage, anemia and other potentially serious medical problems.” Dr. Corley also pointed out that PPIs have been connected to “increased risk in food-borne infections and bone fractures” in earlier research “because these drugs make it difficult to absorb certain nutrients.” In response to the study, Dr. Keith Obstein, a gastroenterologist at Vanderbilt University Medical Center in Nashville and a committee member of the American College of Gastroenterology, said that “the study gives physicians another potential side effect to discuss with their patients.”

        Reuters (12/11, Seaman) reports that Dr. Corley said that those taking the medications should not simply stop, but that they “should have their B12 levels checked.” He also said that patients should take the smallest effective dose and for as little duration as possible. Reuters lists a number of PPIs omeprazole, esomeprazole, and lansoprazole, and H2RAs cimetidine, famotidine, and ranitidine.

        BBC News (12/11) reports that Prof Mark Pritchard of the British Society of Gastroenterology pointed out that “only a minority of patients” who were long-term users of the medications were also B12 deficient. The report found that higher doses led to greater likelihood of deficiency, and the link “was stronger in women and younger age groups,” but it also found that “the overall risk was still low.”

        HealthDay (12/11, Gordon) reports that last year, there were over “150 million prescriptions” for PPIs, while lower doses are available over the counter.

        MedPage Today (12/11, Petrochko) reports the population of those with B12 deficiency was “mostly female (57.4%), 60 or older (67.2%), and were white (68.4%).”

        NPR (12/11, Shute) also covered the study in its “Shots” blog.

Cancer Drug Linked with Decreased Kidney Function

Patients taking crizotinib for the treatment of non-small cell lung cancer experienced an average 23.9% decrease in eGFR during the first 12 weeks of therapy in a recent Cancer study. The study included 38 patients on crizotinib therapy, and their reduced kidney function was most evident in the first 2 weeks of treatment. When crizotinib therapy was stopped, 56% of patients had complete recovery in their eGFR. The renal effects of crizotinib, which blocks a protein made by the mutated anaplastic lymphoma kinase gene, may need to be considered when determining the appropriate duration of crizotinib therapy.

Sodium Restriction May Increase Efficacy of RAAS Blockade

In patients with nondiabetic CKD, sodium restriction on top of single and dual renin-angiotensin-aldosterone system (RAAS) blockade increases circulating levels of the anti-inflammatory and antifibrotic peptide N-acetyl-seryl-aspartyl-lysyl-proline (AcSDKP), according to a secondary analysis of a 46-patient randomized clinical trial. Patients with overt proteinuria and mild-to-moderate renal insufficiency were subjected to four double-blind 6-week study periods with either a regular-sodium or low-sodium diet in addition to either lisinopril or lisinopril plus valsartan. The Journal of Hypertension analysis concludes the rise in AcSDKP may contribute to the enhanced cardiorenal protection of RAAS-blockade during sodium restriction.

Nighttime Blood Pressure Linked with Increased Risk of Developing CKD

Nighttime blood pressure (BP) is a better CKD predictor than daytime BP according to a Journal of Hypertension studyof 843 individuals without CKD at baseline from the general Japanese population. Individuals with a 1–standard deviation (SD) increase in daytime systolic BP had a 13% increased risk of developing CKD over a median of 8.3 years. Those with a 1-SD increase in nighttime systolic BP had a 21% increased risk. When nighttime and daytime BP were mutually adjusted into the same model only nighttime BP persisted as an independent predictor of CKD.

Acute Kidney Injury May Be Deadlier Than Heart Attacks

Patients with acute kidney injury (AKI) or AKI and myocardial infarction (MI) later experienced more major heart and kidney problems than those with MI alone. A CJASN article analyzed 36,980 patients discharged with a diagnosis of AKI or myocardial infarction (MI) who were admitted to a VA facility between October 1999 and December 2005 and followed for a maximum of 6 years depending on the index hospitalization. Deaths occurred most often in patients who experienced both AKI and MI (57.5%), and least often in patients with uncomplicated admissions for MI (32.3%).

No Link between Diastolic Dysfunction and Mortality in Patients with Heart Failure and Kidney Disease

A new study has found that severe diastolic dysfunction does not appear to contribute to the increased mortality risk observed in heart failure patients with renal dysfunction. Researchers analyzed data pertaining to 669 patients in the EchoCardiography and Heart Outcome Study (ECHOS), evaluating whether eGFR was associated with mortality risk before and after adjustment for severe diastolic dysfunction. During a 7-year follow-up period, eGFR was associated with similar mortality risk before and after adjustment for severe diastolic dysfunction according to the BMC Nephrology article.

Higher BMI Linked with Early Kidney Function Decline in Young Adults

Higher BMI categories were associated with greater declines in kidney function in a 10-year study of 2839 black and white young adults with normal kidney function at baseline. Individuals with a BMI of 25.0 to 29.9 were 1.50 times more likely to experience rapid kidney function decline; those with a BMI between 30.0 and 39.9 were 2.01 times more likely; and those with a BMI of 40.0 or higher were 2.57 times more likely. After age 30, average kidney function was progressively lower with each increment in BMI. The findings are published in the American Journal of Kidney Diseases.

Study: Walking faster may prolong life.

The New York Times (12/4, Reynolds) “Well” blog reports a recent study published in PLoS One indicates middle-aged people can improve the benefits of walking for exercise by increasing their pace. According to Lawrence Berkeley National Laboratory statistician Paul T. Williams, “Our results do suggest that there is a significant health benefit to pursuing a faster pace,” as pushing one’s body “appears to cause favorable physiological changes that milder exercise doesn’t replicate.”

Research Links Morning Blood Pressure Surge and Glycemic Control in Diabetics

In a study of 50 patients with type 2 diabetes, poor glycemic control and insulin resistance were independently associated with the occurrence of morning blood pressure surge, which might be significantly associated with endothelial dysfunction. HbA1c and triglyceride correlated significantly and positively with morning blood pressure surge, and they correlated significantly and negatively with brachial artery flow-mediated dilation. The Diabetes Carefindings noted that morning blood pressure surge is known to be an independent predictor of cardiovascular events, but little is known about its association with glycemic control.

Energy drinks may cause serious increases in heart contraction rates.

On its website, CBS News (12/3) reports that research presented at the Radiological Society of North America annual meeting suggests that “energy drinks may cause serious increases in heart contraction rates within an hour of” consuming them.

        The Huffington Post (12/3) reports that investigators “recruited 18 healthy people – 15 men and three women – with an average age of 27.5 to undergo cardiac magnetic resonance imaging before drinking an energy drink containing 32 milligrams/100 milliliters of caffeine and 400 milligrams/100 milliliters of taurine.” One “hour after consuming the drinks, all the participants underwent cardiac MRI to see if energy drink consumption had any effect on heart function.” The investigators “found that the participants’ hearts had increased contraction rates – indicated by increased peak systolic strain in the heart’s left ventricle – after drinking the energy drinks.”

        The Los Angeles Times (12/3, Kaplan) “Science Now” blog reports that the investigators “also looked for changes in heart rate and blood pressure before and after volunteers consumed the energy drink, but the readings in both cases were essentially the same.”

        On its website, FOX News (12/3) reports that researcher Dr. Jonas Dörner, said, “There are concerns about the products’ potential adverse side effects on heart function, especially in adolescents and young adults, but there is little or no regulation of energy drink sales.”

        HealthDay (12/3, Thompson) reports that this “study raises concerns that energy drinks might be bad for the heart, particularly for people who already have heart disease, said Dr. Kim Williams, vice president of the American College of Cardiology.” According to Dr. Williams, “We know there are drugs that can improve the function of the heart, but in the long term they have a detrimental effect on the heart.”

Study: Hospital charges the largest driver of medical inflation

ABC World News reported on “outrageous hospital costs” and “expensive and wildly confusing bills.” The segment focuses on one women who had the same tests performed at two different facilities and then received bills asking her to pay very different amounts. ABC’s Rebecca Jarvis said, “With so many hospitals, doctors, labs and insurance companies negotiating rates confidentially among themselves, patients are at their wits end.”

        In a 3,500-word story front-page story titled, “As Hospital Prices Soar, A Single Stitch Tops $500,” the New York Times (12/3, Rosenthal, Subscription Publication) also reports on high hospital costs and hospitals’ often confusing billing patterns. The “prices for any item or service are set by each hospital and move up and down yearly, and show extraordinary variability, health economists say.” The primary cause of “high hospital costs in the United States, economists say, is fiscal, not medical: Hospitals are the most powerful players in a health care system that has little or no price regulation in the private market.” The article points out that “hospital charges represent about a third of the $2.7 trillion annual United States health care bill, the biggest single segment, according to government statistics, and are the largest driver of medical inflation, a new study in The Journal of the American Medical Association found.” The Times also discusses how emergency departments have, in many cases, become “profit centers.”

        Reuters (12/3, Jegtvig) reports that patients often have no idea how much a medical procedure costs until they have been discharged from the hospital, and a study published online in JAMA Internal Medicine indicates that it would be difficult to find out beforehand. Investigators attempting to obtain price quotes for an electrocardiogram from hospitals in the Philadelphia area. The researchers found that just three of the 20 hospitals provided a quote on how much the test would cost.

Study: “Healthy obesity” does not exist.

NBC Nightly News reported that new research suggests that individuals cannot be simultaneously be overweight and physically fit. NBC’s Chief Medical Editor Dr. Nancy Snyderman said that the research indicates that “there is no such thing as healthy obesity.”

        Reuters (12/3, Pittman) reports that investigators analyzed data from studies that included a total of more than 61,000 participants.

        The Los Angeles Times (12/3, Healy) “Science Now” blog reports that the investigators “found that, as BMI rose, so rose blood pressure, waist circumference and insulin resistance.” Meanwhile, “as BMI increased, levels of HDL cholesterol, thought to protect against heart attack and stroke, decreased.” While participants who were either overweight or obese “may not yet have reached the points that define metabolic illness, they appeared to be on that road as their weight” increased. The research was published online in the Annals of Internal Medicine.

        On its website, Time (12/3, Sifferlin) reports that “since obesity has different effects on the body for different people, researchers are still investigating how weight gain and its health effects may vary among people whose obesity is due primarily to things such as genetics and environmental exposures as opposed to unhealthy diets and lack of physical activity.” The article points out that some of the studies used “in the current meta-analysis” had no “follow-up with the participants, so the final mortality and heart disease rates may be slightly higher or lower than they should be.”

        On its website, NBC News (12/3, Carroll) reports that the findings appear “to contradict a study published earlier this year, which had concluded that overweight individuals might actually be healthier than those with normal weights,” although “the differing results may simply be due to the fact that the new report looked at different data and at long-term outcomes, experts said.” Also covering the story are HealthDay (12/3, Reinberg), MedPage Today (12/3, Boyles), and Medscape (12/3, Laidman).

Friday, November 29, 2013

Increased AKI Admissions in England May Be Tied to ACEI and ARA Prescriptions

A new PLOS ONE analysis suggests that more than 1600 AKI admissions might have been avoided in England in 2010 and 2011 if prescribing rates of ACE inhibitors (ACE-Is) and angiotensin-receptor antagonists (ARAs) were at the 2007 to 2008 level, equivalent to 14.8% of the total increase in AKI admissions. Crude AKI admission rates showed a 51.6% increase, and national annual ACE-I/ARA prescribing rates increased by 15.8%. The increase in prescriptions seen in a typical practice corresponded to an increase in admissions of approximately 5.1%.

Blacks Have Lower Levels of Total 25-Hydroxyvitamin D and Vitamin D–Binding Protein than Whites

In the 2085-participant Healthy Aging in Neighborhoods of Diversity across the Life Span cohort, average levels of both total 25-hydroxyvitamin D and vitamin D–binding protein (which keeps vitamin D from being used right away) were lower in blacks than in whites, leading to similar concentrations of bioavailable vitamin D overall. The NEJMfindings suggest that a low level of total 25-hydroxyvitamin D does not necessarily indicate a need to replace vitamin D. Racial differences in common genetic polymorphisms explained 79.4% and 9.9% of the variation in vitamin D–binding protein and total 25-hydroxyvitamin D levels, respectively.

ACE Inhibitors Cut Mortality in Renal Patients


ACE Inhibitors Cut Mortality in Renal Patients

Published: Nov 21, 2013


Chronic kidney disease patients who did not depend on dialysis were significantly less likely to die during the study period if they received angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), researchers found.

Among older patients with nondialysis chronic kidney disease who had never taken ACE inhibitors and AR blockers, administration of either agent was associated with a 19% lower hazard of death (95% CI 0.78-0.84, P<0.001) in an intention-to-treat analysis, according toCsaba Kovesdy, MD, of the Memphis Veterans Affairs Medical Center in Tennessee, and colleagues.

Subgroup analysis also showed that the association with lower risk of mortality was significant across all subgroups, they wrote online in the Journal of the American College of Cardiology.

Recent research has shown that dual treatment with ARBs and ACE inhibitors has been associated with acute kidney injury and hyperkalemia when compared with monotherapy, and that increased prescription rates for either drug class has been tied to increased risks for renal injuries. However, links between ARBs and myocardial infarction have been dispelled.

The authors conducted an analysis of mortality risk with use of ARBs and ACE inhibitors in a population of 40,494 U.S. veterans with chronic kidney disease that did not require dialysis and who had no prior exposure to treatment with either drug class.

They noted that prior research has been inconclusive, and that much of it has been "limited to patients with certain comorbid characteristics."

Participants' glomerular filtration rate (GFR) was estimated through measurement of serum creatinine and demographic characteristics based on the Chronic Kidney Disease Epidemiology Collaboration equation. This was used to establish the presence of chronic kidney disease, which they defined as a stable estimated GFR of less than 60 mL/min/1.73 m2 or a stable GFR of 60 or more mL/min/1.73 m2 and elevated urinary microalbumin.

Researchers recorded whether participants received ACE inhibitors or ARBs within 1 year after entering the cohort (n=20,247) or if they were untreated during the study (n=20,247).

Patient demographic information was available through the Veterans Affairs Corporate Data Warehouse, which included age, sex, race, and blood pressure, the latter of which was gathered from October 2004 to October 2009. Patients' comorbidities were recorded in the Veterans Affairs Inpatient and Outpatient Medical SAS Datasets, and included coronary artery disease, angina, myocardial infarction, percutaneous coronary intervention receipt, and receipt of coronary artery bypass grafting.

All-cause mortality was reported through a Veterans Affairs registry of death dates or date of last medical or administrative encounter.

Associations between drug treatment and risk for mortality were measured in intention-to-treat and as-treated models, the latter of which allowed patients "to switch treatment groups in time-dependent analyses according to actual subsequent exposure status."

Patients were analyzed in subgroups categorized by sociodemographic characteristics, presence or absence of comorbid conditions, and laboratory and blood pressure variables.

Participants had a mean baseline age of 74.8; 89% were white, 8% were black. Roughly one quarter had diabetes (22%) and they had a mean eGFR of 50 mL/min/1.73 m2.

Patients who received drug treatment were younger, more likely to be black, and were more likely to have diabetes, hypertension, congestive heart failure, and cardiovascular disease. They also had a higher eGFR.

Over a median 4.7 years of follow-up, there were 5,028 deaths in the treatment group versus 6,450 deaths in the untreated group. Most patients received their medication more than half of the time during follow-up (66%), though only 8.4% received their medication 100% of the time during follow-up.

In the as-treated analysis, receipt of ACE inhibitor or ARB was associated with a 63% reduced odds of mortality (95% 0.34-0.41).

The authors noted that uncertainty about the effects of these drugs in non-dialysis dependent patients with chronic kidney disease "stems from the paucity of clinical trials with a mortality end-point in this patient population," such as those with renal end points or with the exclusion of patients with moderate or advanced disease.

Potential mechanisms of effect for this relationship may include decrease of severity of left ventricular hypertrophy, dilation, remodeling, and heart failure with treatment, as well as renoprotection offered by the drugs.

They noted that these data may not generalize to patients outside of the Veterans Affairs system. Their study was also limited by lack of data on end stage renal disease or hospitalizations, lack of data on cause of death, absent information on smoking status, and lack of comparison or measurement of effects of other antihypertensive agents.

The study was supported by the Department of Veterans Affairs.

The authors declared that they had no conflicts of interest

Kidney Impairment Linked with Increased Risk for Postoperative Abdominal Surgery Complications

Any degree of preoperative kidney impairment was linked with increases in 30-day postoperative morbidity and mortality following major abdominal surgery in a recent analysis of 24,572 patients. Compared with patients with normal preoperative kidney function, patients with modest CKD (GFR of 45 to 60 mL/min/1.73 m²) were 1.62 times more likely to die after surgery. Patients with GFR between 30 and 45 mL/min/1.73 m² were 2.84 times more likely to die postsurgery, and those with GFR between 15 and 30 mL/min/1.73 m² were 5.56 times more likely to die. TheJournal of Gastrointestinal Surgery study also found CKD was associated with increased postoperative complications. 

Amgen’s new class of cholesterol drug cuts LDL by 52 percent, study says.

Reuters (11/20, Berkrot, Pierson) reports Amgen Inc.’s experimental heart medicine belonging to a new class of drugs caused a decline in bad LDL cholesterol by 52 percent, without any major jump in serious side effects, after one year. The medicine, evolocumab, belongs to a class of drugs called PCSK9 inhibitors. The side effects were compared with those caused by drugs generally used to treat cholesterol such as statins, reports Reuters. Study results were presented Tuesday at the American Heart Association meeting in Dallas.

Aspirin before bed may reduce morning heart attack, stroke risk.

USA Today (11/19, Hellmich, 5.82M) reports that according to a study presented a Tuesday’s AHA meeting, “taking the aspirin before bed may reduce the chance of having a heart attack or stroke in the morning.” Study author Tobias Bonten of the Leiden University Medical Center in the Netherlands explained, “Platelet activity is highest in the morning, and that is also the time that most heart attacks and strokes occur, so if you reduce platelet activity during the morning hours, you might reduce heart attacks and stroke at that time.”

        The New York Times (11/19, 9.61M) reports in its “Well” blog that Bonten said, “I think in most Western countries, people take aspirin in the morning. It’s already one of our most effective medications. But maybe we can improve it a little bit more by switching the time.”

        Also reporting this story are HealthDay (11/20, 5K), the Daily Telegraph (UK) (11/20, Gray, 3.22M), and the Daily Mail (UK) (11/20, 2.92M).

Dopamine or Nesiritide Does Not Improve Kidney Function in Acute Heart Failure Patients

In 360 hospitalized acute heart failure patients with kidney dysfunction, neither low-dose dopamine nor low-dose nesiritide (recombinant B-type natriuretic peptide) enhanced decongestion or improved renal function when added to diuretic therapy. The JAMA findings come from the multicenter, double-blind, placebo-controlled Renal Optimization Strategies Evaluation (ROSE) trial. Guidelines for acute heart failure management state that use of low-dose dopamine to improve diuresis and preserve renal function during diuretic therapy may be considered, but the ROSE trial findings do not provide support for this strategy in patients with renal dysfunction who are at risk for inadequate decongestion and worsening renal function. 

New Method Rapidly Detects Blood Infections

A new simple and inexpensive method can identify microorganisms in the blood in less than 20 minutes. The method combines a selective lysis step in which blood cells in the sample are destroyed, a centrifugation step to collect any bacteria or fungi in the sample, and a fluorescence step that analyzes the particular fingerprint of any pathogens present in the sample. Tests show the method correctly identifies the species of bacteria or fungi in 96.5 % of positive blood culture samples. The advance, which is described in an mBio article, could help doctors make life-saving decisions for infected patients.

Stenting Does Not Improve Outcomes for Patients with Narrowed Renal Arteries

In a new study, renal-artery stenting did not confer significant benefits with respect to preventing clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic renal-artery stenosis and hypertension or chronic kidney disease. The NEJM results pertain to The CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) study, which involved 947 participants at more than 100 sites in various countries. Participants were randomly assigned to medical therapy plus renal-artery stenting or medical therapy alone, with a median follow-up of 3.6 years. During follow-up, there was a consistent modest difference in systolic blood pressure favoring the stent group. 

Friday, November 15, 2013

Physical Activity Affects Cardiovascular Risks in Patients with Type 2 Diabetes

In a study of 15,462 type 2 diabetics who were followed for 5 years, those in the low physical activity group (never exercising or exercising once or twice a week for 30 minutes) had a 25% greater risk of coronary and cardiovascular events than those in the high activity group (exercising three or more times a week), and a 69% greater risk of a fatal cardiovascular event. Individuals with both baseline and final low physical activity levels had a 68% higher risk of coronary and cardiovascular disease and death than all others in the European Journal of Preventive Cardiology study.

Initiating Dialysis After Conception, Not Before, May Improve Birth Rates

Among all pregnancies reported to the Australian and New Zealand Dialysis and Transplantation Registry from 2001 to 2011, women who conceived before starting dialysis had a better live birth rate than women who conceived after starting dialysis (91% vs. 63%), but their infants were of similar birth weight and gestational age. In both groups, babies were likely to be premature and of low birthweight. According to the CJASN study, more than 40% of pregnancies reached beyond 34 weeks, extreme prematurity occurred in 11.4% of pregnancies, and almost all babies who were born survived beyond 28 days after birth.

Thursday, November 14, 2013

New Guidelines Published for Preventing Cardiovascular Disease

Four new guidelines released by the American College of Cardiology and American Heart Association address cardiovascular disease prevention. They include a new equation for estimating a patient’s risk of having an atherosclerotic cardiovascular disease event in the next 10 years, as well as methods to identify appropriate preventive therapies for individual patients. The guidelines state that statins have the strongest evidence of a favorable risk-benefit ratio. A new risk equation can be used to determine whether patients with diabetes and elevated LDL cholesterol levels should receive high-intensity or moderate-intensity statin therapies. The guidelines also address lifestyle and obesity/overweight management.

Wednesday, November 13, 2013

New guidelines may lead to higher statin use.

New guidelines that could lead to higher statin use among US adults were discussed on all three of last night’s national news broadcasts, where they received a total of eight minutes of coverage. The guidelines also garnered extensive coverage in print, with stories featured on the front pages of at least four major US papers, and online. Many sources portray the guidelines as a major shift in the treatment of high cholesterol. Some of the sources also characterize the guidelines as “controversial.”

        NBC Nightly News reported that “the first new guidelines in a decade about how” statins “should be prescribed” have been released, and they “could result in many more Americans taking these” medications.

        On ABC World News, ABC’s Dr. Richard Besser said that the “new guidelines...dramatically expand” the use of statins “to one third of adults.”

        The CBS Evening News called the new guidelines “controversial,” and reported that they “put less emphasis on cholesterol numbers and more on other risk factors in determining who should take medication.”

        In a second segment on NBC Nightly News, Dr. Tanya Benninson, Chief Medical Officer at NBC Universal, discussed the guidelines.

        In a front-page story, the New York Times (11/13, A1, Kolata, Subscription Publication, 9.61M) reports, “The new guidelines, formulated by the American Heart Association and the American College of Cardiology and based on a four-year review of the evidence, simplify the current complex, five-step process for evaluating who needs to take” the drugs.

        USA Today (11/13, Szabo, 5.82M) reports, “The guidelines identify four high-risk groups who could benefit from statins: people with pre-existing heart disease, such as those who have had a heart attack; people ages 40 to 75 who have diabetes; patients ages 40 to 75 with at least a 7.5% risk of developing cardiovascular disease over the next decade, according to a formula described in the guidelines; and patients with the sort of super-high cholesterol that sometimes runs in families, as evidenced by an LDL of 190 milligrams per deciliter or higher.”

        The Washington Post (11/13, A1, Dennis, Bernstein, 4.28M) reports on its front page that Kim Williams, vice president of the American College of Cardiology said, “Lower [LDL] is better, and no one’s arguing that, but once you have a reason to treat someone, they should be treated fully.”

        In a nearly 1,200-word article on its front page, the Los Angeles Times (11/13, Healy, 3.07M) reports that the new “guidelines will align physician practices with a welter of new research showing what works – and what doesn’t – in preventing heart attacks and strokes, said Dr. Steven Nissen, an influential Cleveland Clinic cardiologist who was not involved in drafting the new” guidelines.

        Bloomberg News (11/13, Cortez, 1.91M) reports that the aim “is to identify people most likely to benefit from treatment and stop trying to hit arbitrary targets that haven’t been proven to improve health, said Neil Stone...chairman of the panel that wrote the cholesterol guidelines.” However, it could “be difficult for some doctors and patients to adjust.”

        In fact, the Wall Street Journal (11/13, A2, Winslow, Subscription Publication, 5.91M) points out that both those in favor of and against the new guidelines are concerned that they will lead to confusion among physicians and patients.

        Additionally, the Boston Globe (11/13, A1, Kotz, 1.75M) reports on its front page that some physicians are concerned that nearly “one-third of American adults could now qualify for lifelong statin use, even if they do not have high cholesterol levels or any signs of heart disease.”

        The AP (11/13, Marchione) points out that the “National Heart, Lung and Blood Institute appointed expert panels to write the new guidelines in 2008, but in June said it would leave drafting them to the” AHA and ACC. In addition to the statin guidelines, “new guidelines on lifestyle and obesity” were released yesterday, “and ones on blood pressure are coming soon.”

        The New York Daily News (11/13, Miller, 3.94M) points out that “the new guidelines were published online” yesterday “and will appear in upcoming issues of the Journal of the American College of Cardiology and the AHA journal Circulation.”

        The Los Angeles Times (11/13, Healy, 3.07M) “Science Now” blog reports that this “new game plan for statins represents a stark shift from approaches embraced by cardiologists and primary care physicians for most of the past decade.”

        Similarly, CNN (11/13, Sloane, 14.53M) reports on its website that the new guidelines are “being called a tectonic shift in the way doctors will treat high cholesterol.” Also covering the story are Reuters (11/13, Berkrot), the CBS News(11/13, Jaslow, 3.87M) website, the NPR (11/13, Knox, 465K) “Shots” blog, AFP (11/13), The Oregonian (11/13, Muldoon, 751K), the Time (11/13, Park, 13.4M) website, Forbes (11/13, Herper, 6.03M), HealthDay (11/13, 5K),Medscape (11/13, O'Riordan, 164K), and the Baltimore Sun (11/13, Cohn, 812K) “Picture of Health” blog.

USPSTF: Little evidence vitamins prevent heart disease, cancer

On its website, Time (11/12, Sifferlin, 13.4M) reports that the “U.S. Preventive Services Task Force [USPSTF] says that for most vitamins and minerals, there is not enough evidence to determine whether the pills can lower risk of heart disease or cancer.” With regard “to beta-carotene (found in carrots and tomatoes) and vitamin E, there is no evidence that they can protect against either heart disease or cancer; in fact, beta-carotene use contributed to an increased risk of lung cancer in smokers.”

        On its website, NBC News (11/12, Fox, 6.79M) reports that an analysis published in the Annals of Internal Medicine was “used as the basis” for the recommendations.

        CQ (11/12, Young, Subscription Publication, 967) reports that the USPSTF “said that ‘eating a diet rich in fruits, vegetables, whole grains, fat-free and low-fat dairy products, and seafood may play a role in the prevention of cancer or cardiovascular disease,’ even though no benefit has been shown for vitamins supplements in this connection.”

        Reuters (11/12, Seaman) quotes Dr. Michael LeFevre, co-vice chair of the USPSTF, as saying, “At this point in time the science is not sufficient for us to estimate how much benefit or harm there is from taking vitamin or multivitamin supplements to prevent cancer or heart disease.”

        MedPage Today (11/12, Neale, 122K) reports that “the guidance” released as a draft recommendation, “applies to primary prevention in healthy adults without nutrient deficiencies, with the exception of women who are pregnant or may become pregnant, a group that ‘should take a daily supplement containing folic acid to help prevent neural tube defects.’” The article points out that “the new proposed guidance is consistent with that from other organizations, including the National Institutes of Health and the Academy of Nutrition and Dietetics, which also found insufficient evidence to recommend the use of multivitamins” as a way to “prevent chronic disease.” HealthDay (11/12, 5K) also covers the story.

Not Getting Enough Sleep May Be Linked to Higher Risk of Heart Disease

Reuters reported that research published online in Sleep Medicine suggests that not getting enough sleep may be linked to a higher risk of heart disease. Researchers found that individuals who usually slept less than six hours per night faced a higher risk of developing hypertension, high cholesterol, and diabetes. They were also more likely to be obese. The study indicated that the effect was strongest in black and Hispanic participants.

Consuming More Vegetable Protein May Help Kidney Disease Patients Live Longer

In 1104 CKD patients participating in the 1988-1994 NHANES III, for each 10 gram increase in vegetable protein intake per day, participants had a 14% lower risk of dying by the end of 2006, after controlling for various factors such as age, smoking, and BMI. Thefindings were presented at ASN Kidney Week 2013. Previous research has shown that compared with animal protein consumption, vegetable protein intake is linked with lower production of uremic toxins. Interventional trials are needed to determine whether increasing vegetable protein will prolong CKD patients’ lives.

FDA unveils “bold” move to phase out trans fat.

News that the FDA plans to eliminate artificial trans fats, which are found in crackers, cookies and many other baked goods, and are said to be responsible for thousands of heart attacks and deaths, was widely covered across the US media Thursday. The move earned praise from many health experts. However, results of a Pew poll and comments from some consumer groups suggest that many oppose the ban, with some seeing it as meddling too much in the food supply. ABC World News reported in its broadcast that the Food and Drug Administration issued a warning that “No amount of trans fat, no matter how small is safe.” The FDA estimates that 7,000 lives would be saved each year if trans fats and other partly hydrogenated oils were banned.

        In its broadcast, NBC Nightly News characterizes the FDA move as a “bold” step, noting that while trans fat, also called as partially hydrogenated oil, makes the food taste better, it can make good cholesterol go bad and “bad cholesterol worse,” and “can make heart trouble for all.”

        CBS Evening News interviewed FDA Commissioner Margaret Hamburg, who pointedly says: “This action will save lives. The CDC estimates that if we can reduce the levels of trans fat currently in the American diet,” the US could prevent heart attacks and save lives.

        The Washington Post (11/8, Dennis, 4.28M) says the move by the FDA is the “most aggressive efforts to limit Americans’ consumption of a specific food ingredient” aimed “at ending the era of trans fats altogether.” The Post provides specific numbers of heart attacks and deaths it can prevent, noting that the ban could prevent 20,000 heart attacks and 7,000 deaths due to heart disease every year. The Post says that though products containing trans fats have “increasingly disappeared from grocery stores and restaurant menus” over the past few years, they “still linger in an array of processed foods, including pancake mix, packaged cookies and ready-made frosting.”

        The move to eliminate trans fat was hailed as “lifesaving” by health experts, says USA Today (11/7, Weise, 5.82M). The paper quotes FDA commissioner Margaret Hamburg as saying, “There really is no safe level of consumption of trans fat.” Dean , a professor of medicine at the University of California-San Francisco, says these fats “increase the shelf life of foods but decrease the shelf life of humans.” Thomas , director of the Centers for Disease Control and Prevention says “5,000 Americans a year die of heart disease because artificial trans fat is in the food supply and another 15,000 will get heart disease.”

        On its website, CBS News (11/8, 3.87M) quotes Dr. David , a cardiologist with the Cleveland Clinic, who says that “trans fatty acids are added to processed foods as an inexpensive way to improve taste and texture and lengthen shelf life, but there are other ways of achieving these results that do not directly promote the development of heart disease.”

        In a front-page article, the Wall Street Journal (11/8, A1, Burton, Jargon, Subscription Publication, 5.91M) says an important moment in the history of trans fat was in middle of the last decade when the FDA mandated that food makers disclose trans fat in food products. The move led food makers to start using oils instead of trans fat, in a bid to stop noting the substance on the “Nutrition Facts” label, reports the Journal.

Prevalence of Dialysis Therapy Is Skyrocketing Worldwide

Worldwide, there has been a 165% increase in dialysis treatments for ESRD over the past two decades, according to research presented at ASN Kidney Week 2013. The prevalence of dialysis therapy for countries with universal dialysis access increased by 134% after adjusting for population growth and aging. For countries without universal dialysis access, adjusted prevalence increased by 102%. The findings come from an analysis of information from the Global Burden of Disease database, national and regional ESRD registries, and a literature review of studies from 1990 and 2010. Data from 26 countries that lack routine access to dialysis were excluded.

Diabetes: Risk Factors, Prevention, and Management

More than 8% of Americans have diabetes and about 35% of American adults have prediabetes. Prediabetes is a condition in which blood glucose levels are higher than normal. Without healthy lifestyle changes, those with prediabetes may develop diabetes. 

To protect your health, get information about:

Risk Factors - Family history, blood pressure, and other factors can affect your chances of developing diabetes. Take a quick test to learn your level of risk. 

Prevention - The onset of Type 2 diabetes can sometimes be prevented or delayed through moderate weight loss, good nutrition, and exercise.

How to Manage Diabetes - If you've been diagnosed with diabetes, learn how to stay healthy and keep the disease under control.

Statistics - Get some basic facts, including the prevalence of Type 1 versus Type 2 diabetes.

Initiating Dialysis Can Cause Burdens for Elderly Patients

n a study of 379 patients aged 75 years and older who initiated dialysis, 75% started treatments in the hospital because of an acute illness or surgery, and loss of independent living frequently occurred following such hospitalizations. Of 254 patients who came from home, 28% died in the hospital or were discharged to hospice, and only 37% could return home. Thirty-nine percent of patients died within 6 months of starting treatment; most of these initiated treatment in the ICU, while patients who started dialysis as outpatients had reasonably good survival. The findings were presented at ASN Kidney Week 2013.

Metformin Lowers Blood Glucose by Reducing Fat in the Liver

Researchers report that when mice with mutated acetyl-CoA carboxylase—which regulates fat production as well as the ability to burn fat—are given the diabetes drug metformin, the drug does not lower the animals’ blood sugar levels. It appears that inhibitory phosphorylation of acetyl-CoA carboxylase is essential for the control of lipid metabolism and for metformin-induced improvements in insulin action. The Nature Medicine findings indicate that metformin does not directly reduce sugar metabolism but instead reduces fat in the liver, which then allows insulin to work better.

Testosterone replacement therapy may be linked to increased heart risks.

Research published in JAMA linking testosterone therapy to higher heart risks was covered on one of last night’s national news broadcasts, as well as on several major websites, although it received little coverage in major print media.

        The CBS Evening News reported that new research suggests that testosterone replacement therapy may be linked to heart risks in certain individuals.

        The Wall Street Journal (11/6, Beck, Subscription Publication, 5.91M) reports that for the study, investigators looked at data on more than 8,700 men with low testosterone who underwent coronary angiography at some time between 2005 and 2011 in the US Veterans Affairs health system.

        The Los Angeles Times (11/6, Healy, 3.07M) “Science Now” blog reports that patients “taking testosterone were 30% more likely to suffer an adverse event – a stroke, a heart attack or death.”

        Forbes (11/6, 6.03M) contributor Larry Husten writes that “after adjusting for differences between the groups there was a significant 29% increase in risk associated with testosterone (CI 1.05-1.58, p = 0.02).” The researchers found that “the effect size was the same in the groups of people who had coronary artery disease and those who did not.”

        AFP (11/6) reports that “the increased risk of catastrophic events was especially notable, said researcher Anne Cappola of the University of Pennsylvania, because ‘the men who were taking testosterone in this study were slightly healthier to begin with.’”

        The CNN (11/6, 14.53M) “The Chart” blog reports, however, that some physicians “who looked at the study questioned the methods, saying many of these men already had heart issues.”

        Bloomberg News (11/6, Ostrow, 1.91M) points out that previous research on “testosterone elderly males, funded by the U.S. National Institute on Aging and run at Boston Medical Center, was” halted after “an audit found it caused more heart attacks and high blood pressure.” Also covering the story are Reuters (11/6, Pittman), the AP (11/6, Tanner), the NBC News (11/6, Alexander, 6.79M) website, HealthDay (11/6, Dotinga, 5K),MedPage Today (11/6, Raeburn, 122K), and Medscape (11/6, O'Riordan, 164K).

Uncontrolled and Resistant Hypertension Increases with Advanced Diabetic Nephropathy

The prevalence of uncontrolled and resistant hypertension increased with advanced diabetic nephropathy in aDiabetes Care study of 3678 patients with type 1 diabetes. In patients with normal urinary albumin excretion, 14.1% were on antihypertensive treatment and 74.6% had uncontrolled blood pressure despite treatment. The corresponding figures were 60.5 and 71.2% for microalbuminuric, 90.3% and 80.0% for macroalbuminuric, 88.6% and 88.1% for dialysis, and 91.2% and 90.4% for kidney transplanted patients. The prevalence of resistant hypertension was 1.2% in the normoalbuminuric, 4.7% in the microalbuminuric, 28.1% in the macroalbuminuric, 36.6% in the dialysis, and 26.3% in the kidney transplant groups.

Recent Gout Guidelines Help Control Kidney Disease in People with Hyperuricemia

In a recent trial, patients with hyperuricemia who took urate lowering therapy and achieved a serum uric acid of less than 6 mg/dL—consistent with the 2012 American College of Rheumatology Guidelines for Management of Gout—experienced a 37% reduction in progression of renal disease. The majority of patients who took urate-lowering therapy during the course of the study were taking allopurinol. The findings, presented at the American College of Rheumatology Annual Meeting, suggest that treating to the guidelines is an effective way of preventing and controlling kidney disease in people with hyperuricemia.

Analysis: Paying living kidney donors may save lives, money.

On its website, NBC News (10/25, Aleccia, 6.79M) reports that, according to an analysis published Oct. 24 in the Clinical Journal of the American Society of Nephrology, “paying living kidney donors $10,000 to give up their organs would save money over the current system based solely on altruism – even if it only boosts donations by a conservative five percent.” For the study, researchers from the University of Calgary “compared cost data from a cohort of kidney patients identified in 2004 and followed them for three years.” Investigators calculated that “paying living kidney donors $10,000 apiece would save about $340 per patient, compared with the ongoing costs of dialysis, and would also provide a modest boost of .11 in quality-adjusted life years.”

        The Time (10/25, Alter, 13.4M) “Healthland” blog points out that “if the money actually results in a 10% or 20% increase, the savings per patient could reach thousands of dollars,” for the reason that “most patients wait 2-3 years for a kidney, and the cost of dialysis during the wait is usually higher than $10,000.” The analysis did not “address ethical concerns or the potential for abuse,” however.

Tuesday, October 22, 2013

Vitamin D Levels Not Linked to Kidney Stone

A recent study of more than 2000 participants who were followed for a median of 19 months found no statistically significant association between vitamin D levels in the blood and incidence of kidney stones. Body mass index was significantly associated with kidney stone risk. Only 13 participants developed kidney stones during the study: eight had 25-hydroxyvitamin D serum levels below 50 ng/mL and five had levels equal to or above 50 ng/mL. The findings are published in the American Journal of Public Health.

ACP issues clinical practice guideline on chronic kidney disease

ACP released a new clinical practice guideline this week on screening, monitoring and treatment of stage 1 to 3 chronic kidney disease (CKD).


The guideline was based on a systematic evidence review that evaluated the relevant English-language literature published from 1985 through November 2011. The clinical outcomes evaluated were all-cause mortality, cardiovascular mortality, composite renal outcomes, end-stage renal disease, quality of life, physical function and activities of daily living. The guideline was published online byAnnals of Internal Medicine on Oct. 22.

ACP's recommendations are as follows:

  • Recommendation 1: ACP recommends against screening for CKD in asymptomatic adults without risk factors for CKD. (Grade: weak recommendation, low-quality evidence)
  • Recommendation 2: ACP recommends against testing for proteinuria in adults with or without diabetes who are currently taking an ACE inhibitor or an angiotensin II receptor blocker. (Grade: weak recommendation, low-quality evidence)
  • Recommendation 3: ACP recommends that clinicians select pharmacologic therapy that includes either an ACE inhibitor (moderate-quality evidence) or angiotensin II receptor blocker (high-quality evidence) in patients with hypertension and stage 1 to 3 CKD. (Grade: strong recommendation)
  • Recommendation 4: ACP recommends that clinicians choose statin therapy to manage elevated low-density lipoprotein in patients with stage 1 to 3 CKD. (Grade: strong recommendation, moderate-quality evidence)

The guideline authors also gave advice to clinicians on provision of high-value care in this population, noting that no evidence shows that screening improves clinical outcomes in adults without risk factors and that there is no proven benefit of screening in adults already taking ACE inhibitors or angiotensin II receptor blockers for microalbuminuria.

"In the absence of evidence that screening improves clinical outcomes, testing will add costs, owing to both the screening test and to additional follow-up tests (including those resulting from false-positive findings), increased medical visits, and costs of keeping or maintaining health insurance," the guideline authors concluded.

Thursday, October 17, 2013

Flaxseed May Reduce Blood Pressure in Hypertensive Patients

In a Hypertension trial of 110 patients who ingested 30 g of milled flaxseed or placebo daily over 6 months, plasma levels of the ω-3 fatty acid α-linolenic acid and enterolignans increased 2- to 50-fold in the flaxseed-fed group but did not increase in the placebo group. Systolic blood pressure (SBP) was about 10 mm Hg lower and diastolic blood pressure (DBP) was about 7 mm Hg lower in the flaxseed group compared with placebo. Flaxseed reduced SBP by 15 mm Hg and reduced DBP by 7 mm Hg in patients with SBP of 140 mm Hg or higher.

Poor Glycemic Control a Major Factor in Overestimating GFR in Diabetics

In a Diabetes Care study of 40 diabetics and 40 non-diabetics, inulin clearance was not significantly different between the two groups, but each of three eGFR measures from the diabetic patients was significantly higher than that of the non-diabetic subjects. There were significant and positive correlations between the ratio of each eGFR/insulin clearance, hemoglobin A1c, and glycated albumin. New formulae for calculating eGFR corrected by the glycemic control indices were better than the original eGFR, particularly in diabetic patients. The findings suggest that eGFR overestimates insulin clearance as glycemic controls worsen, and eGFR corrected by hemoglobin A1c is clinically useful.