Women with sudden cardiac arrest are significantly less likely than men to be previously diagnosed with structural heart disease, according to a prospective study.
Inadequate levels of vitamin D are associated with an increase in the risk of cardiovascular disease and death, a new observational study has found. Dr Tami L Bair (Intermountain Medical Center, Murray, UT) reported the findings here at the American Heart Association 2009 Scientific Sessions.
Bair and colleagues followed more than 27 000 people 50 years or older with no history of cardiovascular disease for just over a year and found that those with very low levels of vitamin D (<15 ng/mL) were 77% more likely to die, 45% more likely to develop coronary artery disease, and 78% more likely to have a stroke than those with normal levels (>30 ng/mL). Those deficient in vitamin D were also twice as likely to develop heart failure as those with normal levels.
"We concluded that even a moderate deficiency of vitamin D was associated with developing coronary artery disease, heart failure, stroke, and death," said coauthor Dr Heidi May (Intermountain Medical Center). However, "it is not known whether this is a cause and effect relationship," she told heartwire. Because this study was observational, more research is needed "to better establish the association between vitamin D deficiency and cardiovascular disease," she noted.
Vitamin D was the subject of much discussion in a general session on vitamins at the AHA scientific sessions. Although the evidence supporting the benefits of vitamin D in cardiovascular disease is probably stronger than for any other vitamin, there have been only a few randomized clinical trials, and previous observational studies "show no robust effects," said Dr Harald Dobnig (Medical University of Graz, Austria). The latter suffer from limitations, such as doses of vitamin D supplementation that are too low, low compliance rates, and short study duration, he noted.
There are some large randomized trials underway looking at outcomes with vitamin D; it is hoped that they will provide definitive answers in five to seven years, Dr Eric Rimm (Harvard School of Public Health, Boston, MA) explained.
"I think there's promise for vitamin D. We know that most people have insufficient vitamin D levels in their blood," Rimm told heartwire. "So although it will take five years until some of the trials that are adequately powered to look at cardiovascular disease with vitamin D will report, the epidemiology right now is suggestive that people should have 1000 or 2000 IU of vitamin D a day," he said.
Rimm discussed vitamin D at length, explaining that there are two sources: sunlight in the form of UVB rays, and diet (foods and supplementation). "Many tissue types and cells in the body have vitamin D receptors, and the active form of vitamin D is modulated by calcium and parathyroid hormone," he explained, with potential downstream effects on a number of bodily systems—inflammatory markers and the renin angiotensin system to name just two—he said.
People at highest risk of vitamin D deficiency include those with darker skin, those living at high altitudes, the elderly (because there is less of the precursor for vitamin D in the blood as people age and older people tend to spend less time outside), the obese, those who avoid the sun or cover the skin in the sun, those who are the immobilized or institutionalized, and pregnant and breast-feeding women.
Deficiency in vitamin D is generally agreed to be a blood level of <20 ng/mL, he said, with 20-29 ng/mL indicating insufficient vitamin D, 30-60 ng/mL indicating adequate vitamin D, and >150 ng/mL indicating excessive vitamin D.
Data suggest that many people are likely getting inadequate vitamin D, he said, with studies showing that black Americans have blood levels ranging from 6-18 ng/mL and that white Americans have levels ranging from 16-25 ng/mL.
In general, a supplement of 100 IU of vitamin D per day will increase blood levels of vitamin D by 1 ng/mL, Rimm said. Those taking 1000 IU per day should have blood levels in the range of 25-32 ng/mL and those taking 4000 IU should have levels of 40-50 ng/mL.
However, Rimm stressed that vitamin D need not just come from supplements. "I think for vitamin D, it's a shame just to count on supplementation because, during the right times of year, five to 10 minutes a day of sunlight is sufficient is to make enough vitamin D. I do hear the concerns about skin cancer and I think people should wear suntan lotion, but it's probably better to put it on 10 minutes after you've been in the sun."
He cautioned that "in northern climes, even if you go out in the sun in January, you're not going to make much vitamin D, so there you would need supplementation to get adequate levels."
One of the best dietary sources of vitamin D is fish.People should remember that diet is an important source of vitamin D, too, he noted. "One of the best dietary sources of vitamin D is fish. We already suggest people eat a couple of servings a week, but having three or four servings a week of fish can get you a fair bit of vitamin D, and would represent an additional 300 to 500 IU of vitamin D. This still might not be sufficient so you might need a little bit of sunlight or to take a vitamin D supplement. It's really a combination of things, that's probably the best approach."
Both Rimm and Dobnig said it is nearly impossible for anyone to suffer adverse effects from too much vitamin D. Those who spend whole days in the sun, such as lifeguards, have vitamin D levels ranging from 45 to 65 ng/mL, said Rimm. "Vitamin D is safe. Hypercalcemia is not a problem, with the rare exception of granulomatous disease," said Dobnig. He added that because vitamin D is a fat-soluble vitamin, it can be given weekly, or even monthly.
Rimm said he hopes ongoing research will inform the vitamin D debate. Data are needed on intermediate end points, such as inflammatory markers and parathyroid hormone, and on "hard" end points, such as coronary artery disease, sudden death, and heart failure, both in primary prevention and in high-risk populations, including those with chronic kidney disease and heart failure.
The results of two large randomized trials are eagerly awaited, he said, including the National Institutes of Health-sponsored VITAL study looking at whether 2000 IU vitamin D and/or 1 g of fish oil (omega-3 fatty-acid supplementation) can reduce the risk of developing heart disease, stroke, or cancer in 20 000 men and women, which is slated to begin in January 2010.
The Thiazolidinedione Intervention with Vitamin D Evaluation (TIDE) study is being coordinated by researchers at McMaster University, Hamilton, ON. This trial is looking at rosiglitazone versus pioglitazone in people with type 2 diabetes at risk of heart disease, but also has a vitamin D versus placebo arm. The primary outcome for the vitamin D arm will be cancer, but there are a number of secondary cardiovascular end points, said Dobnig.
Right now, I think the evidence for vitamin D probably is stronger than the evidence for other vitamins."The evidence for vitamins is not great," Rimm said. "The best thing we can say now is to stop smoking, eat a good diet, and don't be overweight. I think people sometimes lose touch with the most important message of prevention, and jump right to the vitamins thinking that's going to sustain them, so doing what we know first and best is probably the best place to start."
"After that, right now, I think the evidence for vitamin D probably is stronger than the evidence for other vitamins," he concluded.
The Canadian Press (11/13, Ubelacker) reports that "Canadian researchers have pioneered a new way to mend a patient's breastbone after open-heart surgery, using a Superman-strength glue that cuts healing time and reduces pain." The procedure "uses a state-of-the-art adhesive called Kryptonite that rapidly bonds to bone and accelerates the recovery process, says Dr. Paul Fedak, a cardiac surgeon and scientist at the University of Calgary." Dr Fedak "is set to head an international trial using the technique, which will involve 500 patients over the next year or two." Reuters (11/12) also covered the story.
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http://www.medicalnewstoday.com/articles/170648.php
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MedPage Today (11/9, Phend) reported, "Unlike aspirin, clopidogrel (Plavix) appears to work about as well in women as it does in men," according to a meta-analysis appearing in the Journal of the American College of Cardiology. In fact, "clopidogrel reduced cardiovascular events by 7% in women and 16% in men compared with placebo, with only a 'weak' trend for a difference between genders." The researchers found that "major bleeding risk was elevated 43% in women and 22% in men compared with placebo, again without a significant difference." HealthDay (11/9, Edelson) and Reuters (11/10, Steenhuysen) also covered the study
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On their website, CNN (11/5, Young) reports, that commissioner Hamburg also touted a new "drug dosage guidance document" and claimed that better measuring devices "will help patients, parents and other caregivers use the right amount of these medications -- the safest and most effective dose -- especially for children." She also said the agency was currently "working with the Centers for Disease Control and Prevention on estimates for the number of people who die from avoidable medication errors."
The Los Angeles Times (11/5, Zajac) reports that the agency also said they will begin to "scrutinize the information provided to patients, such as package inserts, labels and instructions that pharmacists give when dispensing prescriptions." The AP (11/5, Perrone) also covers the story.
This is actually a distortion of the trial results. Despite the fact that women and men were equally likely to report chest discomfort or other "typical" symptoms of acute coronary syndrome, women were significantly more likely to report nonchest discomfort such as pain in the neck, jaw, and throat.
It has been known for some time now that some women feel "typical heart pain" but some women do not. More often than men, women having a hreat attack present with throat, stomach, or back symptoms.
My conclusion:- men and women need to be educated on the "typical" symptoms of a heart attack- women need to be educated on the "atypical" symptoms of a heart attackIt is caused by a transient, abrupt, marked reduction in the luminal diameter of an epicardial coronary artery leads to myocardial ischemia (decreased blood flow).
Spasm occurs can occur in either normal or diseased vessels. The reduction in diameter is focal and usually at a single site, although spasm in more than one site and diffuse spasm have been described. Spasm typically occurs within 1 cm of an atherosclerotic plaque in a diseased vessel. This process can usually be reversed by nitroglycerin or a calcium channel blocker.
In addition to spasm of large epicardial vessels, a functional abnormality of microvessels may contribute to myocardial ischemia. This occurs predominantly women who had a history of prolonged (>30 min) chest pain.
CLINICAL CHARACTERISTICS
The clinical presentation and profile of the patient with variant angina are generally different from that of the patient with unstable or chronic stable angina:
Although the pathogenesis of coronary vasospastic angina is not well understood, several contributing factors (other than cocaine abuse) have been identified. These include the autonomic nervous system (particularly alpha-adrenergic receptors), endothelial dysfunction, and adhesion molecules.
A variety of factors may contribute to endothelial dysfunction in patients with variant angina, one of these being inflammation.
DIAGNOSIS:
The key finding for the diagnosis of variant angina is the detection of ST segment elevation during chest discomfort with return of the ST segment to baseline upon resolution of symptoms.
Exercise testing — Exercise treadmill testing is of limited value in variant angina since exercise tolerance is usually well preserved.
Coronary angiography — Coronary angiography may demonstrate an apparently normal vessel, or proximal fixed obstruction of varying severity in one or more of the coronary arteries.
Povocative tests — ergonovine and hyperventilation — can be performed in the catheterization laboratory and have been useful in making the diagnosis of suspected variant angina. These tests are done only when the diagnosis of variant angina is suspected, but not firmly established. At present, provocative testing is less frequently performed.
TREATMENT:
MEDICAL THERAPY:
Medical management of variant angina includes risk factor modification, such as cessation of smoking and lipid lowering, and pharmacologic therapy, which begins with the administration of calcium channel blockers (nifedipine, amlodipine, diltiazem, and verapamil) or nitrates. Both classes of drugs are effective in preventing vasoconstriction and promoting vasodilation in the coronary vasculature.
Statins — Endothelial dysfunction is thought to play a role in the development of variant angina and statins can improve endothelial function.
Estrogen therapy has been recommended in postmenopausal women with variant angina because of its beneficial effects on endothelial function. However, the American Heart Association now recommends against the use of hormone replacement therapy because of the findings from the Women's Health Initiative (WHI) and the Heart and Estrogen/Progestin Replacement Study-II (HERS-II), which suggested that estrogen-progestin therapy might cause harm when used for either primary or secondary prevention of cardiovascular disease.
Patients with variant angina alone (ie, no obstructive coronary disease) generally have a good prognosis
Patients with variant angina who also have obstructive coronary artery disease have a worse prognosis that is, in part, determined by the severity of the underlying disease. T
HeartWire (11/3, Stiles) reported, "In a post hoc analysis of the first major trial to have found no statin protective effect overall in patients with chronic heart failure, the efficacy of rosuvastatin...was inversely related to levels of amino-terminal pro-brain natriuretic peptide (NT-proBNP), such that the drug apparently did cut the risk of cardiovascular events in those with less severe disease as gauged by the biomarker." Researchers from the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA) said that "patients with lower plasma concentrations of NT-proBNP had a lower event rate, but seemed to obtain greater benefit from rosuvastatin." The research was published in the Journal of the American College of Cardiology
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HealthDay (11/3, Dotinga) reported that "statins may boost the risk of fatigue and shortness of breath in some patients with heart failure," according to a study presented at the American College of Chest Physicians meeting. Investigators "looked at the medical records of 136 patients with heart failure." The researchers found that individuals "who had diastolic heart failure and took a cholesterol drug had almost half as much exercise tolerance as those with the condition who didn't take the drugs.
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The ACC understands the very real impacts these cuts will have on your practices, your staff and your patients. The College is exploring all options and staff and leaders are working together to help you understand all of your options. Below is a high-level summary of the policy changes finalized in the rule. In addition, we've also provided links to the tools and resources available to you now.
More information over the coming weeks will be provided in Cardiology magazine, ACC News and The ACC Advocate. Please also plan to join ACC CEO Jack Lewin and President Alfred Bove, M.D., F.A.C.C., for an all-member call on Nov. 12 from 4:00 to 5:30 p.m. (EST) to discuss the 2010 rule. To RSVP for the call, click here.
RULE HIGHLIGHTS:
Practice Expense: Despite the hundreds of calls and letters from you, members of Congress and patients, CMS has chosen to incorporate the results of the American Medical Association's Physician Practice Information Survey into its formula for calculating practice expense relative value units (RVUs). In a slight change from the proposed rule, the agency has said the cuts will be phased in over a four-year period versus all at once. With the exception of evaluation and management services, nearly all services that cardiologists perform will see cuts ranging from 10 percent to more than 40 percent for individual services phased in over 4 years. A few key examples for 2010 alone:
As mentioned above, the ACC is exploring several options for stopping the implementation of these cuts. CMS' decision to phase-in the cuts, while not what we would have hoped, is due in large part to your tremendous efforts over the last few months. Your actions clearly had an impact and we strongly encourage you to continue to email your congressional representatives and CMS detailing the ramifications of these cuts as we move into the next phase of challenging these cuts.
Bundled codes for myocardial perfusion/SPECT imaging
CMS's continued pressure to bundled together imaging services reported with multiple codes has now hit myocardial perfusion imaging. In 2010 myocardial perfusion imaging/SPECT studies including wall motion and ejection fraction will now be reported with a single code. CMS decided to substantially reduce the payment for myocardial perfusion imaging as part of this rule by reducing both the physician work value and the practice expense value. To make matters worse, because there is a new code for the service, CMS apparently is not applying the four-year transition of the practice expense cuts and instead is using the fully implemented value. The result is a 36% cut in payment for 2010. This change alone accounts for more than one-third of the projected payment cut to cardiology. ACC will begin immediately to pursue strategies to mitigate this cut. Specifics on the new codes and tips on how to work with health plans to transition to the new codes will be emailed to you next week and also included in the November issue of Cardiology magazine.
Consultations: Payments for consultations provided in office and hospital settings are eliminated under the final rule. The RVUs assigned to these codes will be redistributed to office and hospital visits and services now billed as consultations will be billed as hospital or office visits. This will reduce payments to varying degrees for consultation services.
Malpractice: CMS has chosen to update the malpractice RVUs with data from a new survey of specialty-level malpractice premiums. In addition, CMS has proposed a new method for determining malpractice RVUs for technical component services. The proposed new malpractice RVUs would reduce cardiology payments by 1 percent. However, the impact will vary depending on the mix of services provided.
Equipment utilization: CMS has finalized its proposal to change the agency's formula for calculating the per-procedure cost of diagnostic medical equipment worth more than $1 million. The proposal would assume that all diagnostic equipment with an acquisition cost greater than $1 million is used 90 percent of the time an office is open, thus driving down the practice expense RVUs for services using that equipment. Within cardiology, cardiac MR and cardiac CT services will be subject to payments set based on this utilization assumption. CMS did agree not to apply this cut to equipment for non-hospital cardiac catheterization services.
SGR: As required by current law, the final rule includes a 21.5 percent reduction in Medicare Physician Payment as of Jan. 1, 2010. This cut is in addition to the payment reductions that result from the proposed policy changes described above. In short, there could be as high as a 30 percent cut in Medicare payments for cardiology. However, as in previous years, Congress is expected to pass a one to two year fix this fall. CMS did finalize its proposal to remove physician-administered drugs from the accumulated SGR debt, which makes a fix to SGR less expensive.
They actually rubbed their hands with E Coli and used either soap or hand sanitizer to see which worked better
Results:
"The first thing we noticed is that alcohol-based hand sanitizer clearly works the best. In fact, the CDC says you should use a hand sanitizer containing at least 60 percent alcohol. " The most popular product on the market is Purell, which has 62% alcohol.
"As for soap, the antibacterial soap worked only slightly better than the regular soap."
"The Food and Drug Administration recommends using only regular soap because of worries that germs will develop resistance, and people will develop laziness from high-tech soap. Based on the results that we got, it's really not necessary to use antimicrobials in the products. You can see some difference, but it's really not significant"
PLEASE WASH YOUR HANDS!!!!!
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