Lance E. Sullenberger

Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2 A Double-Blind, Placebo-Controlled Study of Extended-Release Niacin on Atherosclerosis Progression in Secondary Prevention Patients Treated With Statins

Background—Niacin reduces coronary heart disease morbidity and mortality when taken either alone or in combination with statins; however, the incremental impact of adding niacin to background statin therapy is unknown. Methods and Results—This was a double-blind randomized placebo-controlled study of once-daily extended-release niacin (1000 mg) added to background statin therapy in 167 patients (mean age 67 years) with known coronary heart disease and low levels of high-density lipoprotein cholesterol (HDL-C; <45 mg/dL). The primary end point was the change in common carotid intima-media thickness (CIMT) after 1 year. Baseline CIMT (0.884±0.234 mm), low-density lipoprotein cholesterol (89±20 mg/dL), and HDL-C (40±7 mg/dL) were comparable in the placebo and niacin groups. Adherence to niacin exceeded 90%, and 149 patients (89.2%) completed the study. HDL-C increased 21% (39 to 47 mg/dL) in the niacin group. After 12 months, mean CIMT increased significantly in the placebo group (0.044±0.100 mm; P<0.001) and was unchanged in the niacin group (0.014±0.104 mm; P=0.23). Although the overall difference in IMT progression between the niacin and placebo groups was not statistically significant (P=0.08), niacin significantly reduced the rate of IMT progression in subjects without insulin resistance (P=0.026). Clinical cardiovascular events occurred in 3 patients treated with niacin (3.8%) and 7 patients treated with placebo (9.6%; P=0.20). Conclusions—The addition of extended-release niacin to statin therapy slowed the progression of atherosclerosis among individuals with known coronary heart disease and moderately low HDL-C.

The effect of 24 months of combination statin and extended-release niacin on carotid intima‐media thickness: ARBITER 3

ABSTRACT Objective: The ARBITER 2 trial showed that extended-release niacin (ERN) when added to statin monotherapy slowed the progression of carotid atherosclerosis over 12 months. Whether longer treatment with ERN would have a greater effect on carotid intima.media thickness (CIMT) is unknown. Research design and methods: We examined the long-term effects of ERN on high density lipoprotein (HDL-C) cholesterol and CIMT during 12.24 months treatment with ERN in ARBITER 2 participants who were either continued or were crossed over (from placebo) to ERN 1000 mg daily. Main outcome measures: Among 149 subjects completing ARBITER 2, 130 (88%) enrolled in ARBITER 3. The prespecified primary endpoints were the within-group change in CIMT and HDL.C in patients receiving placebo for 12 months (n = 71), ERN for 12 months (comprised of subjects from ERN treatment during ARBITER 2 (n = 78) and those crossed over to ERN from placebo after ARBITER 2 (n = 47)), and ERN for 24 months spanning ARBITER 2 and 3 (n = 57). Five subjects discontinued the study due to flushing side effects. The study was completed by 104 subjects (47 crossed over from placebo; 57 with ERN continued from ARBITER 2). Results: HDL.C increased in the ERN group from 39.5 ± 6.7 to 48.6 ± 13.3 mg/dl (p < 0.001) along with modest reductions in LDL.C and TG. Among 125 participants treated with ERN for 12 months, there was a net regression of CIMT of. 0.027 ± 0.011 mm (p < 0.001 vs. placebo). Among 57 participants treated with ERN for 24 months, there was additional significant regression of CIMT of. 0.041 ± 0.021 mm (p = 0.001 vs. placebo). Controlling for changes in LDL and triglycerides, only changes in HDL.C were independently associated with regression of CIMT (b =. 0.25; p = 0.001). Conclusion: When added to statin therapy, ERN significantly increases HDL.C and induces atherosclerosis regression measured by CIMT over 24 months. Limitations to this study include its open-label design and the inability to relate CIMT effects to clinical outcomes.

Real-world application of coronary computed tomography angiography and its potential effect on downstream resource utilization in evaluating angina

BACKGROUND Evaluating low-risk outpatients with chest pain is a common clinical problem and poses significant demand on clinical resource utilization. Despite the impressive performance characteristics of coronary multislice computed tomography (MSCT) angiography, its implementation in the diagnostic evaluation of outpatient chest pain and its effect on downstream resource utilization remains undefined. OBJECTIVE We compared the effect of a strategy that used MSCT with a traditional strategy (pre-MSCT strategy) in which MSCT was not available on clinical downstream resource utilization, defined as the need for further stress testing or cardiac catheterization. METHODS We retrospectively identified 75 patients without known disease who had undergone MSCT angiography for the primary indication of possible angina. The review of clinical vignettes of these 75 patients and completion of surveys assessing diagnostic strategy by two general cardiologists represented the pre-MSCT diagnostic strategy. Survey responses were compared with the number of cardiac catheterizations and stress tests that actually resulted after MSCT angiography (MSCT strategy). RESULTS A strategy that used MSCT angiography in the evaluation of patients with possible angina would have significantly reduced the need for further stress testing and cardiac catheterizations (58 vs 11; P < 0.005). Furthermore, this strategy would have resulted in significantly fewer unnecessary cardiac catheterizations (6 vs 23; P < 0.005). CONCLUSIONS Coronary MSCT angiography can potentially reduce the need for further stress tests or cardiac catheterizations in the evaluation of low- to intermediate-risk patients with possible angina. Prospective studies are needed to validate these findings and to assess the overall cost effectiveness of implementing MSCT early in the outpatient evaluation of angina.

Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2: a double-blind, placebo-controlled study of extended-release niacin on atherosclerosis progression in secondary prevention patients treated with statins

UNLABELLED This study demonstrates the efficacy of ambulatory blood pressure monitoring to measure anti hypertensive effect. Original Article: White WB, Giles T, Bakris GL, Neutel JM, Davidai G, Weber MA. Measuring the efficacy of antihypertensive therapy by ambulatory blood pressure monitoring in the primary care setting. Am Heart J. 2006;151(1):176-184. KEYWORDS anti hypertensive therapy; blood pressure; hypertension.PRACTICE PEARL This study demonstrates that adding extended-release niacin to statins favorably affects atherosclerotic lesions in the carotid arteries of atherosclerotic coronary heart disease (CHD) patients and moderately low high density lipoprotein cholesterol (HDL-C) levels.

Isolated ventricular noncompaction

2 The patient was a 35-year-old man with palpitations and resyncope. His electrocardiogram and initial echocardioram were normal, but ambulatory electrocardiographic onitoring showed nonsustained polymorphic ventricular achycardia. A 64-slice multidetector cardiac computed toography (CT) (GE Lightspeed VCT; General Electric, ilwaukee, WI) was performed by using dose modulation ith a tube voltage of 100 kVp and tube current of 650 mA t 70% to 80% of the R-R interval. The images showed an bnormal myocardium with a two-layered appearance of the nterior, lateral, inferior, and apical walls (Figs. 1 and 2). he coronary arteries were normal. The layering of the yocardium was characteristic for isolated ventricular nonompaction (IVNC) with a thin, compacted inner band and thicker, noncompacted, outer band with a ratio of the inner o outer layers of 2.4 in diastole. The left ventricular ystolic function was reduced with an ejection fraction of 7% and inferoapical wall hypokinesis (video image). IVNC is an uncommon disorder that results from the ntrauterine arrest of myocardial fiber and meshwork comaction. This developmental failure can lead to the clinical

Letter Regarding Article by Newby et al, “Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease”

To the Editor: We read with interest the article by Newby et al1 regarding adherence to evidence-based secondary prevention therapies in patients with heart disease. This is an important and sobering study, highlighting the need for better use of proven therapies for patients with coronary artery disease and heart failure. We were surprised, however, at the low rate of adherence …