Why is McAllen, a poor town near the border of Mexico, the second most expensive health care market in the US? Although income in McAllen is only $12,000 per capita, Medicare spent 15,000 for each of its members in 2006,  about twice the national average. To find out more, Atul Gawande, a surgeon at Brigham and Women’s Hospital and the Dana Farber Cancer Institute, visited McAllen and spoke to  doctors and others about the situation. You can read his important report in last week’s New Yorker.

Gawande explains that the situation in McAllen has very broad reverberations:

…you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

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Aspirin for primary prevention has “uncertain net value” according to the latest report from the Antithrombotic Trialists’ (ATT) Collaboration in the Lancet.

The new meta-analysis includes data from 95,000 primary prevention patients and 17,000 secondary prevention patients. Previous attempts to analyze existing studies did not include patient-level data, so were unable to assess the risk and benefits in prognostically important groups. “Current guidelines,” the authors write, “largely ignore any differences in bleeding risk, and recommend that aspirin be used widely for primary prevention in those at moderately raised risk of coronary heart disease,” or recommend that aspirin be used in all people at a certain age.
Click to continue reading, including commentary from Harlan Krumholz and Sanjay Kaul…

It shouldn’t come as a big surprise to our readers, but a study from Cincinnati shows that teenagers and young adults who are obese or who have type 2 diabetes are already developing atherosclerotic changes that do not bode well for their future cardiovascular health. The study by Urbina et al appears in Circulation as a rapid access journal report.

The researchers obtained cIMT measurements on 182 lean, 136 obese, and 128 T2DM subjects aged 10 to 24 years. The authors conclude that “adolescents and young adults with obesity and T2DM are at risk for early atherosclerotic changes in the carotid arteries. The abnormalities are only partially explained by traditional cardiovascular risk factors such as age and BP because the presence of obesity or diabetes mellitus contributed independently to carotid structure and function.”
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A new study from Spain is raising concerns about the possible dangers of coronary aneurysms following DES implantation. The study by Alfonso et al is published in the Journal of the American College of Cariology.

In the study,  nearly 1,200 consecutive patients underwent late angiographic evaluation after DES implantation. Coronary aneurysms were found in 15 (1.25%) of patients. Two of the patients had acute MI as a result of DES thrombosis, 4 patients had ACS. Nine patients were asympatomatic, but one subsequently died of cardiogenic shock after MI related to the aneurysm. The complications were related to discontinuation of dual antiplatelet therapy, according to the authors.
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Sports fans often act as if the outcome of a big sporting event is a matter of life and death. They just may be right, according to an article in press published online in the American Journal of Cardiology.

Kloner and colleagues studied total and cardiovascular mortality in Los Angeles in 1980 and 1984. In 1980 the LA Rams lost the Super Bowl; in 1984 the LA Raiders won. The football-loving cardiologists compared the LA County data for the period immediately after the Super Bowl to a control period just afterwards. Compared to the control period, in the Super Bowl-related days in 1980 they found a higher death rate for all deaths, circulatory deaths, deaths from ischemic heart disease, and MI-related deaths. By contrast, in 1984 they found lower rates for these events during the period immediately after the Super Bowl.
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Fenofibrate reduces the rate of amputation in type 2 diabetics by 36%, according to a prespecified analysis of the FIELD trial published today in the Lancet. In its original presentation FIELD failed to find a benefit for fenofibrate therapy in the primary endpoint of reduction of cardiovascular death or MI in diabetic patients, but did offer hope for beneficial effects in secondary and tertiary outcomes.

In an accompanying Comment, Sergio Fazio and MacRae Linton observe that the “results related to these tertiary outcomes are turning out to be of greater scientific interest and of wider clinical relevance than are those for the macrovascular targets.” Statins have not been shown to have an affect on amputation, which Fazio and MacRae say is an “intrinsic limitation to their effectiveness for clinical targets that are not strongly dependent on dyslipidaemia. In view of this background, we should marvel at the unexpectedly large effects of treatment with a fibrate on both diabetic retinopathy and amputations.”

Click to continue reading, including commentary from Darren McGuire…

Early intervention is no better than delayed intervention in ACS patients in reducing the rate of death, MI, or stroke at 6 months, according to results of  the Timing of Intervention in Acute Coronary Syndromes (TIMACS) trial published today in the New England Journal of Medicine.

However, early intervention did reduce the incidence of recurrent ischemia and was superior to delayed intervention in high risk patients.
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Two studies in JAMA this week are likely to be of interest to many readers.

1) After a great deal of hype earlier in the decade, stem cell therapy is no longer attracting a great deal of attention in the cardiology world. Now a new study in JAMA may help revive interest. Bone marrow cell therapy appeared to improve cardiac function and quality of life in patients with chronic ischemia. However, the study included only 50 patients.

2) Most people believe that cardiorespiratory fitness is a strong predictor of mortality and cardiovascular outcomes, but it has been difficult to establish this connection with reliability or precision in individual studies. Now a Japanese meta-analysis of 33 studies provides the best evidence yet linking cardiorespiratory fitness to outcomes. The authors suggest that cardiorespiratory fitness be considered a major risk factor.
Click to read the JAMA press releases…

Cardiovascular researchers have long observed a puzzling paradox: obese people are more likely to develop cardiovascular disease than their skinnier counterparts, but once they do develop cardiovascular disease obese people actually have a better prognosis. The implications of the obesity paradox are discussed in a review article by Carl Lavie and colleagues in JACC.

Lavie notes that we don’t yet understand the mechanisms” for the better outcome of obese patients, he speculates on a number of likely causes, including protective metabolic effects, greater reserves to fight disease, and earlier diagnosis of cardiovascular disease.
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In the real world patients with ICDs live longer than their counterparts in randomized studies, but they also have a higher than anticipated rate of inappropriate shocks. The results of the ALTITUDE prospective observational study of more than 85,000 ICD and CRT-D patients were presented by Leslie Saxon at the  annual meeting of the Heart Rhythm Society in Boston.

The 5 year survival rate was 91.8% in the ICD group and 75.6% in the CRT-D group. At 5 years 35% of patients in both groups had received a shock. Shock was associated with a worse prognosis. The authors concluded: “Inappropriate shocks remain a significant clinical issue and further effort needs to be made to decrease the incidence. These excellent survival data in a cohort much larger than seen in prior trials add support to the use of implantable devices for at risk heart failure patients.”
Click here to read press releases from HRS and Boston Scientific…

Patients who are taking psychotropic drugs such as antipsychotics, antidepressants and benzodiazepines are at increased risk of sudden death during ACS, according to a new case-control study from Finland presented today at the annual meeting of the Heart Rhythm Society.

Comparing  321 sudden cardiac death victims to 609 MI survivors, Jussi Honkola found significantly higher rates of psychotropic drug use among the SCD patients:

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(from WikiDoc— by C. Michael Gibson, M.S., M.D. Dr. Gibson served as a member of the Executive and Steering Committees for the CHAMPION trial)

The phase 3 CHAMPION clinical trial program of the investigational agent cangrelor was discontinued today. The intravenous agent was being evaluated in patients undergoing percutaneous coronary intervention (PCI). The announcement was made by the sponsoring company, The Medicines Company, in a press release.
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Contrary to the ardent belief of supplement supporters and mothers, vitamins may not always be good for you. A new study in the Proceedings of the National Academy of Sciences raises the intriguing possibility that the antioxidant vitamins C and E may actually prevent the healthful benefits of exercise in humans.

German researchers evaluated insulin sensitivity in 39 healthy young men before and after 4 weeks of exercise. Insulin sensitivity was increased only in the absence of antioxidants. The authors “propose an essential role for exercise-induced ROS formation in promoting insulin sensitivity in humans.”
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