Mori J. Krantz

Reduction in the Incidence of Acute Myocardial Infarction Associated With a Citywide Smoking Ordinance

Background— Secondhand smoke exposure increases the risk of acute myocardial infarction (AMI). One study (Helena, Mont) examined the issue and found a decrease in AMI associated with a smoke-free ordinance. We sought to determine the impact of a smoke-free ordinance on AMI admission rates in another geographically isolated community (Pueblo, Colo). Methods and Results— We assessed AMI hospitalizations in Pueblo during a 3-year period, 1.5 years before and 1.5 years after implementation of a smoke-free ordinance. We compared the AMI hospitalization rates among individuals residing within city limits, the area where the ordinance applied, versus those outside city limits. We also compared AMI rates during this time period with another geographically isolated but proximal community, El Paso County, Colo, that did not have an ordinance. A total of 855 patients were hospitalized with a diagnosis of primary AMI in Pueblo between January 1, 2002, and December 31, 2004. A reduction in AMI hospitalizations was observed in the period after the ordinance among Pueblo city limit residents (relative risk [RR]=0.73, 95% confidence interval [CI] 0.63 to 0.85). No significant changes in AMI rates were observed among residents outside city limits (RR=0.85, 95% CI 0.63 to 1.16) or in El Paso County during the same period (RR=0.97, 95% CI 0.89 to 1.06). The reduction in AMI rate within Pueblo differed significantly from changes in the external control group (El Paso County) even after adjustment for seasonal trends (P<0.001). Conclusions— A public ordinance reducing exposure to secondhand smoke was associated with a decrease in AMI hospitalizations in Pueblo, Colo, which supports previous data from a smaller study.

The effect of giving global coronary risk information to adults: a systematic review.

BACKGROUND Global coronary heart disease (CHD) risk estimation (ie, a quantitative estimate of a patients chances of CHD calculated by combining risk factors in an empirical equation) is recommended as a starting point for primary prevention efforts in all US adults. Whether it improves outcomes is currently unknown. METHODS To assess the effect of providing global CHD risk information to adults, we performed a systematic evidence review. We searched MEDLINE for the years 1980 to 2008, Psych Info, CINAHL, and the Cochrane Database and included English-language articles that met prespecified inclusion criteria. Two reviewers independently reviewed titles, abstracts, and articles for inclusion and assessed study quality. RESULTS We identified 20 articles, reporting on 18 unique fair or good quality studies (including 14 randomized controlled studies). These showed that global CHD risk information alone or with accompanying education increased the accuracy of perceived risk and probably increased intent to start therapy. Studies with repeated risk information or risk information and repeated doses of counseling showed small significant reductions in predicted CHD risk (absolute differences, -0.2% to -2% over 10 years in studies using risk estimates derived from Framingham equations). Studies providing global risk information at only 1 point in time seemed ineffective. CONCLUSIONS Global CHD risk information seems to improve the accuracy of risk perception and may increase intent to initiate CHD prevention among individuals at moderate to high risk. The effect of global risk presentation on more distal outcomes is less clear and seems to be related to the intensity of accompanying interventions.

Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: A meta-analysis of randomized trials

BACKGROUND The benefit of aspirin to prevent cardiovascular events in subjects without clinical cardiovascular disease relative to the increased risk of bleeding is uncertain. METHODS A meta-analysis of randomized trials of aspirin versus placebo/control to assess the effect of aspirin on major cardiovascular events (MCEs) (nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death), individual components of the MCE, stroke subtype, all-cause mortality, and major bleeding. Nine trials involving 102,621 patients were included: 52,145 allocated to aspirin and 50,476 to placebo/control. RESULTS Over a mean follow-up of 6.9 years, aspirin was associated with a reduction in MCE (risk ratio [RR] 0.90, 95% CI 0.85-0.96, P < .001). There was no significant reduction for myocardial infarction, stroke, ischemic stroke, or all-cause mortality. Aspirin was associated with hemorrhagic stroke (RR 1.35, 95% CI 1.01-1.81, P = .04) and major bleeding (RR 1.62, 95% CI 1.31-2.00, P < .001). In meta-regression, the benefits and bleeding risks of aspirin were independent of baseline cardiovascular risk, background therapy, age, sex, and aspirin dose. The number needed to treat to prevent 1 MCE over a mean follow-up of 6.9 years was 253 (95% CI 163-568), which was offset by the number needed to harm to cause 1 major bleed of 261 (95% CI 182-476). CONCLUSIONS The current totality of evidence provides only modest support for a benefit of aspirin in patients without clinical cardiovascular disease, which is offset by its risk. For every 1,000 subjects treated with aspirin over a 5-year period, aspirin would prevent 2.9 MCE and cause 2.8 major bleeds.

Left ventricular hypertrophy and cardiovascular mortality by race and ethnicity.

BACKGROUND Left ventricular hypertrophy is a major independent risk factor for cardiovascular mortality. The contribution of left ventricular hypertrophy to racial and ethnic differences in cardiovascular mortality is poorly understood. METHODS We used data from the Third National Health and Nutrition Examination Survey and from the National Death Index to compare mortality for those with an electrocardiographic (ECG) diagnosis of left ventricular hypertrophy to those without left ventricular hypertrophy separately for whites, African Americans, and Latinos. We used Cox proportional hazards regression to control for other known prognostic factors. RESULTS ECG left ventricular hypertrophy was significantly associated with 10-year cardiovascular mortality in all 3 racial/ethnic groups, both unadjusted and adjusted for other known prognostic factors. The hazard ratio for this association was significantly greater for African Americans (2.31; 95% confidence interval [CI], 1.55-3.42) than for whites and Latinos (1.32; 95% CI, 1.14-1.76 and 2.11; 95% CI, 1.35-3.30, respectively), independent of systolic blood pressure. CONCLUSIONS ECG left ventricular hypertrophy contributes more to the risk of cardiovascular mortality in African Americans than it does in whites. Using regression of ECG left ventricular hypertrophy as a goal of therapy might be a means to reduce racial differences in cardiovascular mortality; prospective validation is required.

Effects of Methadone on QT‐Interval Dispersion

Study Objective. To evaluate the effects of methadone on QT‐interval dispersion.

Comparison of Two Point-of-Care Lipid Analyzers for Use in Global Cardiovascular Risk Assessments

Background: Point-of-care (POC) lipid testing is increasingly used in community-and office-based practice. Two analyzers commonly used in the US are CardioChek PA and Cholostech LDX. Both directly measure total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C), mandatory values in calculating a Framingham Risk Score (FRS). The FRS in turn informs the clinician of the need for lipid-modifying therapy and the degree of therapeutic intensity. Objective: To compare the performance of CardioChek PA and Cholestech LDX. Methods: Staff members from the Colorado Prevention Center were included in the study, with all having fasted for 12 hours beforo the testing. No medical history was obtained. A venous blood sample was collected for lipid measurements conducted in a laboratory, and 2 finger sticks were obtained at that time and analyzed immediately on-site using the POC analyzers. Intraclass correlation coefficients (ICCs) were determined for each analyzer versus the laboratory analysis, with values greater than 0.75 defined as Indicators of excellent reproducibility. We then assessed how interanalyzer differences in TC or HDL-C impacted the FRS lipid categorization. Results: Thirty-four adults (aged 24-56 y) participated in the study. The ICC between Cholestech LDX and the laboratory standard exceeded 075 for all 4 lipid categories (TC, p = 0.96; HDL-C, p = 0.88; low-density lipoprotein cholesterol, ρ = 0.87; triglycerides, ρ = 0.99). By contrast, the only ICC exceeding 0.75 using CardioChek PA was for triglycerides (ρ = 0.84). When applied in calculating the FRS, the Cholestech LDX analyzer misclassified fewer individuals for TC versus the CardioChek PA analyzer (5 vs 21). Overall, Cholestech LDX provided TC and HDL-C values in the correct FRS category more frequently versus CardioChek PA (TC, p < 0.001; HDL-C, p > 0.001). Limitations of the study include use of only 2 POC products and small sample size with no known risk factors. This project does not prove superior accuracy of either device, but reflects a real-world comparison of the analyzers conducted at a single center. Conclusions: The Cholestech LDX analyzer demonstrated better reproducibility than the CardioChek PA analyzer when compared with laboratory gold standard analysis and allowed more accurate categorization for FRS. Since results obtained from these analyzers have the potential to impact treatment decisions, larger, prospective, comparative studies seem warranted.

Effects of buprenorphine on cardiac repolarization in a patient with methadone-related torsade de pointes

Torsade de pointes is a rare but potentially fatal ventricular arrhythmia that is often triggered by drugs that prolong the rate‐corrected QT (QTc) interval. This arrhythmia has been attributed to levacetylmethadol and methadone, synthetic opioids used to treat heroin addiction. Levacetylmethadol, a derivative of methadone, is being withdrawn from the United States market because its use waned after a black box warning was issued to require electrocardiographic monitoring. Therefore, methadone and buprenorphine are the only opioids available for the treatment of heroin addiction. To our knowledge, the cardiac safety of buprenorphine in patients with methadone‐related QTc prolongation has not been described. We report a patient who developed torsade de pointes while receiving high‐dose methadone and was successfully inducted onto buprenorphine under close medical supervision. No clinically important QTc prolongation was observed in the acute setting or during follow‐up. This observation suggests that buprenorphine may be a safe alternative to oral methadone in patients with opioid addiction who develop torsade de pointes.

Anorexia Nervosa Medical Issues

Anorexia nervosa is an increasingly common chronic psychiatric disorder with a multitude of medical complications. Most of these complications are reversible if there is timely restoration of body weight. A few of them, particularly osteoporosis, refeeding complications, and cardiac arrhythmia, are potentially much more serious. In the end, a multidisciplinary team approach with input from a primary care provider who is familiar with these medical sequelae, together with psychiatric and dietary expertise, can effectuate a successful outcome.

Patterns and Predictors of Evidence-Based Medication Continuation Among Hospitalized Heart Failure Patients (from Get With the Guidelines–Heart Failure)

Hospitalized patients with heart failure and decreased ejection fraction are at substantial risk for mortality and rehospitalization, yet no acute therapies are proven to decrease this risk. Therefore, in-hospital use of medications proved to decrease long-term mortality is a critical strategy to improve outcomes. Although endorsed in guidelines, predictors of initiation and continuation of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β blockers, and aldosterone antagonists have not been well studied. We assessed noncontraindicated use patterns for the 3 medications using the Get With the Guidelines-Heart Failure (GWTG-HF) registry from February 2009 through March 2010. Medication continuation was defined as treatment on admission and discharge. Multivariable logistic regression using generalized estimating equations was used to determine factors associated with discharge use. In total 9,474 patients were enrolled during the study period. Of those treated before hospitalization, overall continuation rates were 88.5% for ACE inhibitors/ARBs, 91.6% for β blockers, and 71.9% for aldosterone-antagonists. Of patients untreated before admission, 87.4% had ACE inhibitors/ARBs and 90.1% had β blocker initiated during hospitalization or at discharge, whereas only 25.2% were started on an aldosterone antagonist. In multivariate analysis, admission therapy was most strongly associated with discharge use (adjusted odds ratios 7.4, 6.0, and 20.9 for ACE inhibitors/ARBs, β blockers, and aldosterone antagonists, respectively). Western region, younger age, and academic affiliation were also associated with higher discharge use. Although ACE inhibitor/ARB and β-blocker continuation rates were high, aldosterone antagonist use was lower despite potential eligibility. In conclusion, being admitted on evidence-based medications is the most powerful, independent predictor of discharge use.

QT Interval Screening in Methadone Maintenance Treatment: Report of a SAMHSA Expert Panel

ABSTRACT In an effort to enhance patient safety in opioid treatment programs, the Substance Abuse and Mental Health Saervices Administration convened a multi-disciplinary Expert Panel on the Cardiac Effects of Methadone. Panel members (Appendix A) reviewed the literature, regulatory actions, professional guidances, and opioid treatment program experiences regarding adverse cardiac events associated with methadone. The Panel concluded that, to the extent possible, every opioid treatment program should have a universal Cardiac Risk Management Plan (incorporating clinical assessment, electrocardiogram assessment, risk stratification, and prevention of drug interactions) for all patients and should strongly consider patient-specific risk minimization strategies (such as careful patient monitoring, obtaining electrocardiograms as indicated by a particular patients risk profile, and adjusting the methadone dose as needed) for patients with identified risk factors for adverse cardiac events. The Panel also suggested specific modifications to informed consent documents, patient education, staff education, and methadone protocols.