Thursday, August 19, 2010
hart kleppen
More European Results on Transcatheter Aortic Valve Implantation
Encouraging findings from a study of short-term registry data
Treatment of aortic stenosis with transcatheter aortic valve implantation (TAVI) is becoming routine outside the U.S.; two devices are now available. These investigators report 30-day outcomes in 32 European centers participating in the manufacturer-sponsored SOURCE registry following commercial release of the SAPIEN device.
The cohort included 1038 adults (mean age, 81), 463 of whom received the device transfemorally (TF) and 575 transapically (TA). All patients were at high risk (logistic EuroSCORE, 29% with TA; 26% with TF) for complications of surgical aortic valve replacement (AVR). The procedural success rate was >90%, but important complications included valve embolization (0.3%), coronary obstruction (0.6%), and conversion to surgical AVR (2.7%). Adverse events at 30 days included death (8.5%), new need for a pacemaker (7.0%), major vascular complications (7.0%), renal failure requiring dialysis (4.3%), and stroke (2.5%). Mortality was slightly higher — and vascular complications lower — in the TA group than in the TF group; the authors attributed the increased mortality in the TA group to their higher baseline risk profile.
Comment: This early real-world experience with a TAVI device in high-risk patients with aortic stenosis demonstrates a high short-term procedural success rate and low overall 30-day mortality — and also reveals opportunities for improvement (e.g., avoidance of vascular complications, valve malposition). Data on long-term survival and comparison with surgically and medically managed patients are needed to further define the role of this new therapy.
— Howard C. Herrmann, MD
Published in Journal Watch Cardiology August 18, 2010
Encouraging findings from a study of short-term registry data
Treatment of aortic stenosis with transcatheter aortic valve implantation (TAVI) is becoming routine outside the U.S.; two devices are now available. These investigators report 30-day outcomes in 32 European centers participating in the manufacturer-sponsored SOURCE registry following commercial release of the SAPIEN device.
The cohort included 1038 adults (mean age, 81), 463 of whom received the device transfemorally (TF) and 575 transapically (TA). All patients were at high risk (logistic EuroSCORE, 29% with TA; 26% with TF) for complications of surgical aortic valve replacement (AVR). The procedural success rate was >90%, but important complications included valve embolization (0.3%), coronary obstruction (0.6%), and conversion to surgical AVR (2.7%). Adverse events at 30 days included death (8.5%), new need for a pacemaker (7.0%), major vascular complications (7.0%), renal failure requiring dialysis (4.3%), and stroke (2.5%). Mortality was slightly higher — and vascular complications lower — in the TA group than in the TF group; the authors attributed the increased mortality in the TA group to their higher baseline risk profile.
Comment: This early real-world experience with a TAVI device in high-risk patients with aortic stenosis demonstrates a high short-term procedural success rate and low overall 30-day mortality — and also reveals opportunities for improvement (e.g., avoidance of vascular complications, valve malposition). Data on long-term survival and comparison with surgically and medically managed patients are needed to further define the role of this new therapy.
— Howard C. Herrmann, MD
Published in Journal Watch Cardiology August 18, 2010
Sunday, August 15, 2010
kramp
Conclusion
Although it's clear that quinine and its derivatives should no longer be used routinely to treat muscle cramps, the absence of this treatment option leaves a significant gap in physicians' ability to effectively treat a common problem of older adults. Original research is required to establish a new standard, using either older medications or new ones, for the treatment of muscle cramps.
Clinical Pearls
* Muscle cramps might occur in up to half of older adults, but some research suggests that the majority of patients do not report these symptoms to their physician.
* The current review suggests that non-pharmacologic interventions to treat muscle cramps are probably not helpful.
* Quinine and its derivatives may improve muscle cramps, but these medications are associated with significant, primarily hematologic, adverse event. They should not be used routinely for the treatment of muscle cramps.
* Small studies have suggested that gabapentin, diltiazem, and B complex vitamins are effective for muscle cramps. However, the results of these studies should be confirmed in larger trials.
Although it's clear that quinine and its derivatives should no longer be used routinely to treat muscle cramps, the absence of this treatment option leaves a significant gap in physicians' ability to effectively treat a common problem of older adults. Original research is required to establish a new standard, using either older medications or new ones, for the treatment of muscle cramps.
Clinical Pearls
* Muscle cramps might occur in up to half of older adults, but some research suggests that the majority of patients do not report these symptoms to their physician.
* The current review suggests that non-pharmacologic interventions to treat muscle cramps are probably not helpful.
* Quinine and its derivatives may improve muscle cramps, but these medications are associated with significant, primarily hematologic, adverse event. They should not be used routinely for the treatment of muscle cramps.
* Small studies have suggested that gabapentin, diltiazem, and B complex vitamins are effective for muscle cramps. However, the results of these studies should be confirmed in larger trials.
Friday, August 13, 2010
cholesterol statines
Lipid Levels in Young Adults and Subsequent Coronary Calcium
Adverse consequences of dyslipidemia begin early in life.
Dyslipidemia among middle-aged and older people leads to coronary artery disease (CAD). The consequences of dyslipidemia during young adulthood is the subject of this prospective U.S. study, in which more than 3200 young adults (age range, 18–30) underwent periodic serial lipid measurements for 2 decades after enrollment in 1985. At 15 to 20 years of follow-up, when participants were about 45, coronary calcium studies were performed.
Only 13% of participants maintained LDL cholesterol levels <100 mg/dL ( is 2,5 mmol/l) throughout young adulthood. After controlling for multiple coronary risk factors, LDL cholesterol levels in young adulthood were strongly predictive of coronary calcium 2 decades later. For example, the prevalence of coronary calcium was 8% among individuals with average LDL cholesterol levels <70 mg/dL, ( is 1,8 mmol/l ) but was 44% among those with average LDL cholesterol levels ≥160 mg/dL ( is 4,1 mmol/l.). There was a weaker relation between HDL cholesterol levels and coronary calcium and no significant relation for triglycerides.
Comment: This study documents what most clinicians would have anticipated — the adverse consequences of dyslipidemia begin early in life — and it highlights the need to focus on diet, weight, and exercise throughout life. ( and much easier, moreover take a statin too, opmerking van de zender van dit bericht)
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine August 12, 2010
L.S.
Bovenstaande is een mooi artikel om de stelling te verdedigen dat het niet alleen belangrijk is hoe je je voelt op dit moment, maar van belang is hoe je je eventueel zult voelen als je eventueel oud wordt bijvoorbeeld 80 of nog ouder. Om ook later goede bloedvaten te hebben, wat belangrijk is in verband met dementeren, herseninfarcten, THIA's en hart kwalen, moet vroegtijdig de basis gelegd worden. Een van de voornaamste zaken in dit verband is het nemen van een statine, ook al is je cholesterol op dit moment normaal.
Beste wensen Jan
Adverse consequences of dyslipidemia begin early in life.
Dyslipidemia among middle-aged and older people leads to coronary artery disease (CAD). The consequences of dyslipidemia during young adulthood is the subject of this prospective U.S. study, in which more than 3200 young adults (age range, 18–30) underwent periodic serial lipid measurements for 2 decades after enrollment in 1985. At 15 to 20 years of follow-up, when participants were about 45, coronary calcium studies were performed.
Only 13% of participants maintained LDL cholesterol levels <100 mg/dL ( is 2,5 mmol/l) throughout young adulthood. After controlling for multiple coronary risk factors, LDL cholesterol levels in young adulthood were strongly predictive of coronary calcium 2 decades later. For example, the prevalence of coronary calcium was 8% among individuals with average LDL cholesterol levels <70 mg/dL, ( is 1,8 mmol/l ) but was 44% among those with average LDL cholesterol levels ≥160 mg/dL ( is 4,1 mmol/l.). There was a weaker relation between HDL cholesterol levels and coronary calcium and no significant relation for triglycerides.
Comment: This study documents what most clinicians would have anticipated — the adverse consequences of dyslipidemia begin early in life — and it highlights the need to focus on diet, weight, and exercise throughout life. ( and much easier, moreover take a statin too, opmerking van de zender van dit bericht)
— Jamaluddin Moloo, MD, MPH
Published in Journal Watch General Medicine August 12, 2010
L.S.
Bovenstaande is een mooi artikel om de stelling te verdedigen dat het niet alleen belangrijk is hoe je je voelt op dit moment, maar van belang is hoe je je eventueel zult voelen als je eventueel oud wordt bijvoorbeeld 80 of nog ouder. Om ook later goede bloedvaten te hebben, wat belangrijk is in verband met dementeren, herseninfarcten, THIA's en hart kwalen, moet vroegtijdig de basis gelegd worden. Een van de voornaamste zaken in dit verband is het nemen van een statine, ook al is je cholesterol op dit moment normaal.
Beste wensen Jan
Thursday, August 12, 2010
cholesterol HDL
The JUPITER study previously found that rosuvastatin could significantly improve cardiovascular and other outcomes among adults with LDL cholesterol levels less than 130 mg/dL but with high-sensitivity C-reactive protein levels of 2 mg/L or higher. In a previous analysis by Ridker and colleagues, which was published in the November 20, 2008, issue of the New England Journal of Medicine, rosuvastatin 20 mg daily reduced the risk for myocardial infarction by 54% vs placebo. In addition, rosuvastatin significantly reduced the risk for stroke by 48% and all-cause mortality by 20%.
HDL cholesterol level has been inversely related to the risk for cardiovascular disease, but previous research has questioned whether treatment with statins obviates the higher risk for cardiovascular events associated with low HDL cholesterol levels. The current analysis of the JUPITER study addresses this issue.
Study Highlights
* Patients with diabetes or previous cardiovascular disease were excluded from the JUPITER cohort.
* Participants were randomly assigned to receive rosuvastatin 20 mg daily or placebo.
* The aim of the current study was to determine the relative impact of HDL cholesterol and apolipoprotein A1 levels on the risk for a primary cardiovascular endpoint among participants receiving rosuvastatin or placebo. The primary cardiovascular endpoint included myocardial infarction, stroke, unstable angina, a revascularization procedure, or cardiovascular death.
* 17,802 individuals participated in the study. The mean age of subjects was 66 years, and 38% of participants were women.
* Rosuvastatin treatment raised HDL cholesterol concentrations by an average of 4% vs placebo. Rosuvastatin significantly improved cardiovascular outcomes among participants divided into quartiles based on their baseline HDL cholesterol levels.
* Among participants receiving placebo, the lowest quartile of HDL cholesterol concentration experienced a 46% increase in the risk for cardiovascular events vs the highest quartile.
* However, the same was not true among participants receiving rosuvastatin. The risk for cardiovascular events was similar regardless of HDL quartile among these individuals.
* Similarly, the risk for cardiovascular events was inversely related to the concentration of apolipoprotein A1 among participants in the placebo group but not in the rosuvastatin group.
Clinical Implications
* In the JUPITER study, the use of rosuvastatin reduced the risks for myocardial infarction, stroke, and overall mortality vs placebo among patients with a normal LDL cholesterol level but an elevated high-sensitivity C-reactive protein level.
* The current study demonstrates that HDL cholesterol and apolipoprotein A1 concentrations may not be significant in predicting the risk for cardiovascular events among patients already receiving high-dose statin therapy.
HDL cholesterol level has been inversely related to the risk for cardiovascular disease, but previous research has questioned whether treatment with statins obviates the higher risk for cardiovascular events associated with low HDL cholesterol levels. The current analysis of the JUPITER study addresses this issue.
Study Highlights
* Patients with diabetes or previous cardiovascular disease were excluded from the JUPITER cohort.
* Participants were randomly assigned to receive rosuvastatin 20 mg daily or placebo.
* The aim of the current study was to determine the relative impact of HDL cholesterol and apolipoprotein A1 levels on the risk for a primary cardiovascular endpoint among participants receiving rosuvastatin or placebo. The primary cardiovascular endpoint included myocardial infarction, stroke, unstable angina, a revascularization procedure, or cardiovascular death.
* 17,802 individuals participated in the study. The mean age of subjects was 66 years, and 38% of participants were women.
* Rosuvastatin treatment raised HDL cholesterol concentrations by an average of 4% vs placebo. Rosuvastatin significantly improved cardiovascular outcomes among participants divided into quartiles based on their baseline HDL cholesterol levels.
* Among participants receiving placebo, the lowest quartile of HDL cholesterol concentration experienced a 46% increase in the risk for cardiovascular events vs the highest quartile.
* However, the same was not true among participants receiving rosuvastatin. The risk for cardiovascular events was similar regardless of HDL quartile among these individuals.
* Similarly, the risk for cardiovascular events was inversely related to the concentration of apolipoprotein A1 among participants in the placebo group but not in the rosuvastatin group.
Clinical Implications
* In the JUPITER study, the use of rosuvastatin reduced the risks for myocardial infarction, stroke, and overall mortality vs placebo among patients with a normal LDL cholesterol level but an elevated high-sensitivity C-reactive protein level.
* The current study demonstrates that HDL cholesterol and apolipoprotein A1 concentrations may not be significant in predicting the risk for cardiovascular events among patients already receiving high-dose statin therapy.
Tuesday, August 10, 2010
vitamine D
Is Low Vitamin D Associated with Depression in Elders?
Perhaps, but this community-based U.K. study did not explore all possible contributors.
Deficiencies of several vitamins, notably folate and B12, have been associated with depressive symptoms in people aged 65 and older. In this 2005 British national epidemiological household sample, investigators assessed whether low levels of serum 25-hydroxyvitamin D (25[OH]D) were associated with depressed mood in 2070 community-dwelling elders (mean age, 74; 950 men).
The overall prevalence of case-level depressive symptoms was 25.2%. Analyses were adjusted for age, sex, long-term illness, general health status, time of year (to account for sunlight variation), supplement intake, and smoking. Among the 9.8% of this population with clinically meaningful deficiency (25[OH]D levels <10>
Comment: Although these researchers examined proxies such as general health status, they did not report patients' sunlight exposure, dietary habits, or serum calcium levels. Because many mechanisms could link low serum vitamin D levels to depressive symptoms, identifying the association is only a first step. Vitamin D deficiencies in older individuals may result from inadequate sunlight exposure due to living at high latitudes or to problems with mobility or pain or both. As the authors note, other variables might include vitamin supplementation and smoking. Furthermore, low vitamin D levels may reflect the presence of hypercalcemia associated with undetected hyperparathyroidism, of which depressive features represent a classic clinical presentation. Clinicians should remember these possible contributors to depression when assessing elders.
Published in Journal Watch Psychiatry August 9, 2010
Monday, August 09, 2010
hersen infarct
Newer-Generation Computed Tomography Is Highly Sensitive for Diagnosing Subarachnoid Hemorrhage
But don't put away those lumbar puncture trays just yet.
Older-generation computed tomography (CT) scanners proved too insensitive for a negative scan to rule out the diagnosis of subarachnoid hemorrhage (SAH), making lumbar puncture (LP) necessary in patients with negative scans. In a retrospective chart review, researchers evaluated the sensitivity of newer-generation multidetector CT scanners for diagnosing SAH in 499 patients with suspected SAH who were referred to a Dutch neurosurgical unit from 2000 through 2005.
All patients underwent head CT. Patients with negative CT scans underwent LP (
12 hours after onset of symptoms), and cerebrospinal fluid (CSF) samples were analyzed for xanthochromia by spectrophotometry. Patients with positive scans underwent angiography. SAH was diagnosed in 296 patients, based on angiography or CSF findings. Overall, CT scanning had a sensitivity of 99.7% and a specificity of 100% for diagnosing SAH. Sensitivity was 100% for scans performed 1 to 5 days after symptom onset and 96% for those performed thereafter.
Comment: This study suffers from referral bias, with an extremely high proportion of patients ruling in for subarachnoid hemorrhage (almost 60%). Although newer-generation multidetector CT was highly sensitive, the authors note that CT alone should be used to exclude SAH only on days 1 to 3 after symptom onset and scans should be reviewed by a neuroradiologist or neurosurgeon. Although this study takes us a step closer to eliminating the need for lumbar puncture in patients with suspected SAH, keep those LP trays handy until these results are duplicated in a community emergency department setting.
— Diane M. Birnbaumer, MD, FACEP
Published in Journal Watch Emergency Medicine August 5, 2010
Friday, August 06, 2010
cholesterol apolipoprotein A 1
zoep apolipoprotein A 1 op Wikipedia
Apolipoprotein A-I is a protein that in humans is encoded by the APOA1 gene.[1][2] It has a specific role in lipid metabolism.
Apolipoprotein A-I is the major protein component of high density lipoprotein (HDL) in plasma. The protein promotes cholesterol efflux from tissues to the liver for excretion. It is a cofactor for lecithin cholesterolacyltransferase (LCAT) which is responsible for the formation of most plasma cholesteryl esters. ApoA-I was also isolated as a prostacyclin (PGI2) stabilizing factor, and thus may have an anticlotting effect.[3] Defects in the gene encoding it are associated with HDL deficiencies, including Tangier disease, and with systemic non-neuropathic amyloidosis.[4]
colesterol apolipoproteins
Apolipoproteins are proteins that bind to lipids (oil-soluble substances such as fat and cholesterol) to form lipoproteins, which transport the lipids through the lymphatic and circulatory systems.
The lipid components of lipoproteins are not soluble in water. However, because of their detergent-like (amphipathic) properties, apolipoproteins and other amphipathic molecules (such as phospholipids) can surround the lipids, creating the lipoprotein particle that is itself water-soluble, and can thus be carried through water-based circulation (i.e., blood, lymph).
HDL cholesterol
Free Full-Text Article
Summary and Comment
HDL and Cardiovascular Risk in the Presence of Very Low LDL
HDL levels were not associated with residual cardiovascular risk in patients treated with potent statin therapy.
Population-based studies show that HDL levels <40 href="http://cardiology.jwatch.org/cgi/content/full/2008/1110/1">JW Cardiol Nov 10 2008). A total of 17,802 patients with elevated high-sensitivity C-reactive protein levels and baseline LDL levels <130>
At 2 years, the composite event rate was 44% lower (P<0.0001)>P=0.0047). However, in the rosuvastatin group, the median on-treatment LDL level was 54 mg/dL (1.4 mmol/L), and neither baseline nor on-treatment HDL level was associated with cardiovascular risk. Likewise, low apolipoprotein A1 levels were associated with a significant increase in the composite event rate in the placebo group but not in the rosuvastatin group.
Comment: These findings suggest that HDL levels do not predict cardiovascular events in patients who attain very low LDL levels with potent statin therapy for primary prevention. As editorialists note, these results should not distract from the fact that raising HDL cholesterol with lifestyle changes and drugs such as niacin might provide additional cardiovascular benefit in the majority of patients on statin therapy who do not attain very low LDL cholesterol levels. However, we don't yet know whether such strategies or novel HDL-raising agents will improve outcomes in these patients.
Published in Journal Watch Cardiology August 4, 2010
Citation(s):
Ridker PM et al. for the JUPITER Trial Study Group. HDL cholesterol and residual risk of first cardiovascular events after treatment with potent statin therapy: An analysis from the JUPITER trial. Lancet 2010 Jul 31; 376:333.
Medline abstract (Free)
Hausenloy DJ et al. Dissociating HDL cholesterol from cardiovascular risk. Lancet 2010 Jul 31; 376:305.
Medline abstract (Free)
HDL cholesterol
SUMMARY AND COMMENT
HDL and Cardiovascular Risk in the Presence of Very Low LDL
August 4, 2010 | Beat J. Meyer, MD
HDL levels were not associated with residual cardiovascular risk in patients treated with potent statin therapy.
Reviewing: Ridker PM et al. for the JUPITER Trial Study Group. Lancet 2010 Jul 31; 376:333
Hausenloy DJ et al. Lancet 2010 Jul 31; 376:305
Monday, August 02, 2010
posttraumatische stress disorder
SUMMARY AND COMMENT
Identifying War Veterans at Risk for Mental Health Issues
- July 26, 2010
- Joel Yager, MD
Anger and hostility are correlated with hyperarousal in Iraq and Afghanistan war veterans.
- Reviewing:
- Elbogen EB et al. Am J Psychiatry 2010 Jun 15
kalktabletten calcium osteoporosis osteoporose.
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Calcium supplements linked to increased MI risk
30 July 2010
MedWire News: Study findings suggest that calcium supplements are associated with an increased risk for myocardial infarction (MI).
In meta-analyses of 11 placebo-controlled trials, researchers found a 30% increased relative risk for MI over 4 years in people taking calcium supplements (≥500 mg/day) for the prevention or treatment of osteoporosis.
The risk seemed to be greater in people with above-median dietary calcium intake but was independent of age, gender, and type of supplement, report Ian Reid (University of Auckland, New Zealand) and colleagues in the British Medical Journal.
Small, nonsignificant increases in the risk for stroke and total mortality were also observed with calcium supplementation.
“As calcium supplements are widely used these modest increases in risk of cardiovascular disease might translate into a large burden of disease in the population,” write Reid and team.
The researchers did both patient-level and trial-level analyses. In five trials with patient-level data, including 8151 participants, 143 people allocated to calcium had a MI over the median 3.6-year follow-up compared with 111 allocated to placebo, equating to a hazard ratio for incident MI of 1.31 (p=0.035).
Analysis of trial-level data gave a similar result: among 8151 participants, 166 people who took calcium compared with 130 in the placebo group had a MI over follow-up lasting a mean of 4.0 years, giving a pooled relative risk of 1.27 (p=0.038).
Subgroup analyses suggested that the increased risk for MI with calcium treatment was evident in those with dietary calcium intake above the median of 805 mg/day (HR=1.85) but not in those with lower dietary calcium intake (HR=0.98).
The researchers emphasize that the trials included people taking calcium supplements alone, and “the results therefore may not apply to coadministered calcium and vitamin D supplements.”
They conclude: “Given the modest benefits of calcium supplements on bone density and fracture prevention, a reassessment of the role of calcium supplements in the management of osteoporosis is warranted.”
John Cleland (University of Hull, UK) and colleagues point out in a related editorial that although vitamin D seems to mitigate against the increased risk in cardiovascular events with calcium, there are no conclusive data to show that vitamin D supplements, either alone or combined with calcium supplements, reduce fracture risk either.
However, among other treatments shown to be effective for osteoporosis, bisphosphonates and raloxifene have generally been given in addition to calcium and vitamin D, they note.
Speaking to MedWire News, Cleland commented that it was surprising to see only a trend towards increased mortality despite the increase in MIs, leading him to question whether “the calcium, rather than causing more heart attacks, was actually just causing more heart attacks to be diagnosed.”
So, if taking the calcium caused indigestion, he explained, this could lead to a person having a precautionary electrocardiogram, which picks up a previous MI that otherwise would not have been diagnosed.
Until more research is completed, he said, “you have to back off and take a look at the bigger picture, and the fact is that calcium supplements don’t seem to do much good, and there is a worry that they might cause some harm.”
There are certain patient groups, for example people with malabsorption syndromes, or kidney disease, that may need to continue calcium supplementation, he noted.
“But for the average person in their 50s [or older] worried about developing osteoporosis, I don’t think there is any evidence that calcium meaningfully alters their likelihood of developing a fracture and there is this concern that it may increase the risk of vascular events, so on balance they should probably stop taking them.”
