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ISCHAEMIC HEART DISEASE
Atorvastatin 80 mg for all ACS patients? ▸
Patients with acute coronary syndrome (ACS) need lipid lowering agents. How low should the LDL (low density lipoprotein) cholesterol value go? A total of 4162 patients who had ACS < 10 days before received either 40 mg of pravastatin (standard treatment) or 80 mg of atorvastatin daily (intensive treatment). The primary end point was a composite of death from any cause, myocardial infarction, documented unstable angina requiring rehospitalisation, revascularisation (performed at least 30 days after randomisation), and stroke. Follow up lasted a mean of two years. The median LDL cholesterol concentration achieved during treatment was 95 mg/dl (2.46 mmol/l) in the standard dose pravastatin group and 62 mg/dl (1.60 mmol/l) in the high dose atorvastatin group (p < 0.001). Kaplan-Meier estimates of the rates of the primary end point at two years were 26.3% in the pravastatin group versus 22.4% in the atorvastatin group (16% reduction in favour of atorvastatin, p = 0.005; 95% confidence interval (CI) 5% to 26%).
A new way to raise HDL ▸
Low HDL (high density lipoprotein) cholesterol is an independent risk factor for coronary heart disease. Statins have only a minor effect on HDL values, and nicotinic acid, which raises HDL, is poorly tolerated. Thus the appearance of torcetrapib, a potent inhibitor of CETP (cholesteryl ester transfer protein) is welcome. In 19 subjects with low HDL cholesterol (< 40 mg/dl or 1.0 mmol/l), nine of whom were also treated with 20 mg of atorvastatin daily, subjects received placebo for four weeks and then received 120 mg of torcetrapib daily for the following four weeks. Six of the subjects who did not receive atorvastatin also participated in a third phase, in which they received 120 mg of torcetrapib twice daily for four weeks. Treatment with 120 mg of torcetrapib daily increased plasma concentrations of HDL cholesterol by 61% (p < 0.001) and 46% (p = 0.001) in the atorvastatin and non-atorvastatin cohorts, respectively, and treatment with 120 mg twice daily increased HDL cholesterol by 106% (p < 0.001). Torcetrapib also reduced LDL cholesterol by 17% in the atorvastatin cohort (p = 0.02). The next question will be if this translates into a tolerable and effective treatment for patients at risk of coronary heart disease.
Length of stay post-AMI is declining: ▸
The study sample consisted of 4551 patients discharged after acute myocardial infarction (AMI) from all greater Worcester, Massachusetts, hospitals in eight annual periods. Regression models were used to examine the influence of demographic, clinical, and treatment variables on length of stay and the association between declining length of hospital stay and post-discharge mortality. Notable declines were observed in the average length of stay between the 1986–88 (11.7 days) and 1997–99 (5.9 days) periods. Factors associated with a longer hospital stay included advanced age, female sex, anterior and Q wave MI, and occurrence of clinically important cardiac complications. Increased 30 and 90 day mortality was associated with a length of stay of greater than 14 days (odds ratio (OR) 2.08, 95% CI 1.18 to 3.66) relative to those with a length of stay of 6–8 days (OR 2.01, 95% CI 1.34 to 3.01). Patients with a length of stay of less than six days exhibited no significant increases in post-discharge mortality. Similar trends were observed in patients with a complicated AMI.
Lower the number of doses of antihypertensive agents to increase compliance ▸
Lack of adherence to blood pressure lowering medication is a major reason for poor control of hypertension worldwide. The objective of this study was to determine the effectiveness of interventions to increase patient compliance. Some 38 studies testing 58 different interventions and containing data on 15 519 patients were conducted between 1975 and 2000. The duration of follow up ranged from 2–60 months. Simplifying dosing regimens increased adherence in seven of nine studies, with a relative increase in adherence of 8–19.6%. Motivational strategies were partly successful in 10 of 24 studies with generally small increases in adherence up to a maximum of 23%. Complex interventions comparing more than one technique increased adherence in eight of 18 studies, ranging from 5% to a maximum of 41%. Patient education alone seemed largely unsuccessful.
Patients on warfarin have a 50% mortality after intracerebral bleeding ▸
Warfarin sodium is highly effective for prevention of embolic stroke, particularly in non-valvar atrial fibrillation, but its expected benefit can be offset by risk of intracerebral haemorrhage (ICH). Of 435 consecutive patients aged 55 years or older, 102 (23.4%) were taking warfarin at the time of ICH. Three month mortality was 25.8% for those not taking warfarin and 52.0% for those taking warfarin. Independent predictors of death were warfarin use (OR 2.2, 95% CI 1.3 to 3.8), age 70 years or older (OR 2.4, 95% CI 1.4 to 4.0), and presence of diabetes mellitus (OR 1.8, 95% CI 1.0 to 3.3). Although 68.0% of all warfarin related haemorrhages occurred at an international normalised ratio (INR) of 3.0 or less, increasing degrees of anticoagulation were strongly associated with increasing risk of death compared with no warfarin use. Thus strict control of INR may reduce the severity as well as the incidence of ICH.
American Journal of Medicine; American Journal of Physiology: Heart and Circulatory Physiology; Annals of Emergency Medicine; Annals of Thoracic Surgery; Archives of Internal Medicine; BMJ; Chest; European Journal of Cardiothoracic Surgery; Lancet; JAMA; Journal of Clinical Investigation; Journal of Diabetes and its Complications; Journal of Immunology; Journal of Thoracic and Cardiovascular Surgery; Nature Medicine; New England Journal of Medicine; Pharmacoeconomics; Thorax
Dr Diana Gorog, Dr Akhil Kapur, Dr Masood Khan, Dr Alistair Lindsay; Dr Andrew Sharp