Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines, 2004

ATP III

Coronary CT and Calcium scoring

Coronary CT and Calcium scoring

Application of Coronary Calcium in Symptomatic Individuals

The presence or absence of coronary calcium can significantly alter the posterior probability of CAD for individuals presenting with chest pain.  The calculator below shows how these probabilities are affected and computes similar data for exercise treadmill testing. Note that coronary calcium compares favorably with exercise testing for evaluation of chest pain syndromes and often has a higher negative predictive value, especially in women were exercise treadmill testing is known to be weak.

Clinical Characteristics

Age Range: 30-3940-4950-59 60-69

Gender: Male Female

Presentation: Asymptomatic, ScreenNonAnginal Chest Pain Atypical AnginaAngina

Prior Probability of CAD: 

Posterior Probability of CAD if Coronary Calcium Present:

Posterior Probability of CAD if Coronary Calcium Absent:

Compare the result for Treadmill Testing with Exercise EKG:

Posterior Probability of CAD if Exercise EKG positive:

Posterior Probability of CAD if Exercise EKG negative:

Screening for Osteoporosis

   






Full text, USPSTF 2011


FRAX (fracture risk assessment tool for South Korean)

Smoking Cessation

1. Treating tobacco use and dependence: US department of health and human services - Public health service, 2008



2. Smoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communities. 2008


3. University of Michigan Health System. Smoking cessation. Ann Arbor (MI): University of Michigan Health System; 2006

4. Varenicline for smoking cessation: National institute for health and clinical excellence

Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials, Lancet 2010

Lancet. 2010 Dec 6. [Epub ahead of print]
Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials.

Rothwell PM, Fowkes FG, Belch JF, Ogawa H, Warlow CP, Meade TW.

Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK.
Abstract

BACKGROUND: Treatment with daily aspirin for 5 years or longer reduces subsequent risk of colorectal cancer. Several lines of evidence suggest that aspirin might also reduce risk of other cancers, particularly of the gastrointestinal tract, but proof in man is lacking. We studied deaths due to cancer during and after randomised trials of daily aspirin versus control done originally for prevention of vascular events.

METHODS: We used individual patient data from all randomised trials of daily aspirin versus no aspirin with mean duration of scheduled trial treatment of 4 years or longer to determine the effect of allocation to aspirin on risk of cancer death in relation to scheduled duration of trial treatment for gastrointestinal and non-gastrointestinal cancers. In three large UK trials, long-term post-trial follow-up of individual patients was obtained from death certificates and cancer registries.

RESULTS: In eight eligible trials (25 570 patients, 674 cancer deaths), allocation to aspirin reduced death due to cancer (pooled odds ratio [OR] 0·79, 95% CI 0·68-0·92, p=0·003). On analysis of individual patient data, which were available from seven trials (23 535 patients, 657 cancer deaths), benefit was apparent only after 5 years' follow-up (all cancers, hazard ratio [HR] 0·66, 0·50-0·87; gastrointestinal cancers, 0·46, 0·27-0·77; both p=0·003). The 20-year risk of cancer death (1634 deaths in 12 659 patients in three trials) remained lower in the aspirin groups than in the control groups (all solid cancers, HR 0·80, 0·72-0·88, p<0·0001; gastrointestinal cancers, 0·65, 0·54-0·78, p<0·0001), and benefit increased (interaction p=0·01) with scheduled duration of trial treatment (≥7·5 years: all solid cancers, 0·69, 0·54-0·88, p=0·003; gastrointestinal cancers, 0·41, 0·26-0·66, p=0·0001). The latent period before an effect on deaths was about 5 years for oesophageal, pancreatic, brain, and lung cancer, but was more delayed for stomach, colorectal, and prostate cancer. For lung and oesophageal cancer, benefit was confined to adenocarcinomas, and the overall effect on 20-year risk of cancer death was greatest for adenocarcinomas (HR 0·66, 0·56-0·77, p<0·0001). Benefit was unrelated to aspirin dose (75 mg upwards), sex, or smoking, but increased with age-the absolute reduction in 20-year risk of cancer death reaching 7·08% (2·42-11·74) at age 65 years and older.

INTERPRETATION: Daily aspirin reduced deaths due to several common cancers during and after the trials. Benefit increased with duration of treatment and was consistent across the different study populations. These findings have implications for guidelines on use of aspirin and for understanding of carcinogenesis and its susceptibility to drug intervention. FUNDING: None. Copyright © 2010 Elsevier Ltd. All rights reserved. PMID: 21144578 [PubMed - as supplied by publisher]

Authorized only...

Osteoarthritis, Management

1. The care and management of osteoarthritis in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008

2. The care and management of osteoarthritis in adults. London (UK), Summary, NGC 2008

3. Clinician's guide to prevention and treatment of osteoporosis: National osteoporosis foundation, 2010

abdominal fat - standarized technique for measurement at CT, Radiology 1999

ABSTRACT

The authors estimated abdominal fat distribution on the basis of measurements at computed tomography (CT). The attenuation range for fat tissue was defined as the interval within the mean plus or minus 2 SDs considered to be individual variation. Fat areas found with this method were closely correlated with those obtained by means of the computed planimetric method or with a fixed attenuation range from −190 to −30 HU as the standard of reference. Although the average CT numbers obtained with different scanners were distributed widely, the calculated fat areas were almost identical. This method might be a practical and standardized method at CT.

Abdominal obesity, as calculated with indexes such as the waist-to-hip circumference ratio, is related to metabolic disorders and hypertension and to an increased frequency of total mortality and cardiovascular disease (1–3). In recent years, intraabdominal visceral fat accumulation has been suggested as playing an important and etiologic role in these relationships (4–6). Computed tomography (CT) is an optimal technique for the accurate assessment of intraabdominal fat (7,8). We previously developed a method for measuring the fat volume in the human body by using this technique (7). Several studies revealed that visceral fat areas from a single scan obtained at the level of the umbilicus (approximately the level of L4 and L5) were highly correlated with the total visceral fat volume (7–9). Accordingly, a technique for the measurement of abdominal fat distribution based on findings at CT may be a practical and widely usable method for the evaluation of visceral fat accumulation, which is one of the most important cardiovascular risk factors. In the literature, however, several different attenuation ranges have been used to measure adipose tissue. Since the areas measured on the basis of different attenuation ranges may not be identical, we developed and evaluated a standardized method for measuring abdominal fat volume with CT.

Fat CT, Radiology 1999

n-3 Fatty Acids and Cardiovascular Events after Myocardial infarction

CONCLUSIONS
Low-dose supplementation with EPA–DHA or ALA did not significantly reduce the rate of major cardiovascular events among patients who had had a myocardial infarction and who were receiving state-of-the-art antihypertensive, antithrombotic, and lipid-modifying therapy. (Funded by the Netherlands Heart Foundation and others; ClinicalTrials.gov number, NCT00127452.)


2010, NEJM

Effect of sibutramine on cardiovascular outcomes i... [N Engl J Med. 2010] - PubMed result

N Engl J Med. 2010 Sep 2;363(10):905-17.
Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects.
James WP, Caterson ID, Coutinho W, Finer N, Van Gaal LF, Maggioni AP, Torp-Pedersen C, Sharma AM, Shepherd GM, Rode RA, Renz CL; SCOUT Investigators.

Collaborators (389)
London School of Hygiene and Tropical Medicine, London, England. jeanhjames@aol.com
Comment in:

N Engl J Med. 2010 Sep 2;363(10):972-4.

Abstract
BACKGROUND: The long-term effects of sibutramine treatment on the rates of cardiovascular events and cardiovascular death among subjects at high cardiovascular risk have not been established.

METHODS: We enrolled in our study 10,744 overweight or obese subjects, 55 years of age or older, with preexisting cardiovascular disease, type 2 diabetes mellitus, or both to assess the cardiovascular consequences of weight management with and without sibutramine in subjects at high risk for cardiovascular events. All the subjects received sibutramine in addition to participating in a weight-management program during a 6-week, single-blind, lead-in period, after which 9804 subjects underwent random assignment in a double-blind fashion to sibutramine (4906 subjects) or placebo (4898 subjects). The primary end point was the time from randomization to the first occurrence of a primary outcome event (nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest, or cardiovascular death).

RESULTS: The mean duration of treatment was 3.4 years. The mean weight loss during the lead-in period was 2.6 kg; after randomization, the subjects in the sibutramine group achieved and maintained further weight reduction (mean, 1.7 kg). The mean blood pressure decreased in both groups, with greater reductions in the placebo group than in the sibutramine group (mean difference, 1.2/1.4 mm Hg). The risk of a primary outcome event was 11.4% in the sibutramine group as compared with 10.0% in the placebo group (hazard ratio, 1.16; 95% confidence interval [CI], 1.03 to 1.31; P=0.02). The rates of nonfatal myocardial infarction and nonfatal stroke were 4.1% and 2.6% in the sibutramine group and 3.2% and 1.9% in the placebo group, respectively (hazard ratio for nonfatal myocardial infarction, 1.28; 95% CI, 1.04 to 1.57; P=0.02; hazard ratio for nonfatal stroke, 1.36; 95% CI, 1.04 to 1.77; P=0.03). The rates of cardiovascular death and death from any cause were not increased.

CONCLUSIONS: Subjects with preexisting cardiovascular conditions who were receiving long-term sibutramine treatment had an increased risk of nonfatal myocardial infarction and nonfatal stroke but not of cardiovascular death or death from any cause. (Funded by Abbott; ClinicalTrials.gov number, NCT00234832.)

PMID: 20818901 [PubMed - indexed for MEDLINE]


Effect of sibutramine on cardiovascular outcomes i... [N Engl J Med. 2010] - PubMed result

Family Physicians Play Major Role in Preventing, Treating Obesity, Say Experts -- AAFP News Now -- American Academy of Family Physicians

Family Physicians Play Major Role in Preventing, Treating Obesity, Say Experts -- AAFP News Now -- American Academy of Family Physicians

Quality of Care Among Obese Patients, Vol. 303 No. 13, April 7, 2010

Quality of Care Among Obese Patients
Virginia W. Chang, MD, PhD; David A. Asch, MD, MBA; Rachel M. Werner, MD, PhD
JAMA. 2010;303(13):1274-1281.

Context Clinicians often have negative attitudes toward obesity and express dissatisfaction in caring for obese patients. Moreover, obese patients often feel that clinicians are biased or disrespectful because of their weight. These observations raise the concern that obese patients may receive lower quality of care.

Objective To determine whether performance on common outpatient quality measures differs by patient weight status.

Design, Setting, and Participants Eight different performance measures were examined in 2 national-level patient populations: (1) Medicare beneficiaries (n = 36 122) using data from the Medicare Beneficiary Survey (1994-2006); and (2) recipients of care from the Veterans Health Administration (VHA) (n = 33 550) using data from an ongoing performance-evaluation program (2003-2004).

Main Outcome Measures Performance measures among eligible patients for diabetes care (eye examination, glycated hemoglobin [HbA1c] testing, and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening. Measures were based on a combination of administrative claims, survey, and chart review data.

Results We found no evidence that obese or overweight patients were less likely to receive recommended care relative to normal-weight patients. Moreover, success rates were marginally higher for obese and/or overweight patients on several measures. The most notable differentials were observed for recommended diabetes care among Medicare beneficiaries: comparing obese vs normal-weight patients with diabetes, obese patients were more likely to receive recommended care on lipid screening (72% vs 65%; odds ratio, 1.37 [95% confidence interval, 1.09-1.73]) and HbA1c testing (74% vs 62%; odds ratio, 1.73 [95% confidence interval, 1.41-2.11]). All analyses were adjusted for sociodemographic factors, health status, clinical complexity, and visit frequency.

Conclusions Among samples of patients from the Medicare and VHA populations, there was no evidence across 8 performance measures that obese or overweight patients received inferior care when compared with normal-weight patients. Being obese or overweight was associated with a marginally higher rate of recommended care on several measures.

Author Affiliations: Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Department of Medicine, University of Pennsylvania School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania (Drs Chang, Asch, and Werner); and Department of Sociology, University of Pennsylvania (Dr Chang), Philadelphia, Pennsylvania. Quality of Care Among Obese Patients, Vol. 303 No. 13, April 7, 2010

Quit Smoking guidelines

1. Treating Tobacco Use and Dependence: 2008 Update AHQR

2. Treating Tobacco Use and Dependence: A Quick Reference Guide for Clinicians, 2008 AHQR

ACS :: Guide to Quitting Smoking

ACS :: Guide to Quitting Smoking

Hostile Behaviors Predict Cardiovascular Mortality Among Men Enrolled in the Multiple Risk Factor Intervention Trial, 2004 Circulation

Background—Hostility is associated with incident coronary disease in most large population-based studies, but little is known about its association with cardiovascular disease (CVD) mortality in high-risk individuals. The aim of this study was to assess the association of hostility with CVD mortality in the subsequent 16 years in the Multiple Risk Factor Intervention Trial (MRFIT) participants and to explore the influence of hostility in the subset that had a nonfatal CVD event during the trial.

Methods and Results—We coded the Structured Interview responses of 259 men who died of CVD during the 16 years of follow-up and 259 matching living control subjects. Signs of hostility were assessed by use of the Interpersonal Hostility Assessment Technique. Matching was based on center, intervention group, age, race, and interviewer; covariates included study entry diastolic blood pressure, cholesterol, smoking status, and nonfatal CVD event during the trial. High-hostile men were more likely to die of CVD than were low-hostile men. Adjusted odds ratio (OR) and 95% confidence intervals (CIs) were 1.61, 1.09 to 2.39. After the trial, high -hostile men who also had a nonfatal event during the trial were particularly likely to die of CVD, OR, 5.06, 1.42 to 8.22, compared with low-hostile men without a nonfatal event during the trial.

Conclusions—Hostility may be a risk factor for CVD mortality among high-risk men. Interventions aimed at anger management and stress reduction along with risk factor modification may be useful for hostile patients.
Authorized only

Does Anxiety Increase Risk Of Cardiovascular Disease?

Science Daily, Nov. 16, 2008


Ref)
Association between Anxiety and Factors of Coagulation and Fibrinolysis, 2008 Psychotherapy and Psychosomatics


Background: Psychological stress and anxiety have been shown to produce an activation of coagulation and fibrinolysis. Resulting hypercoagulability is a risk factor for cardiovascular diseases, and could therefore contribute to an increased
prevalence of coronary artery disease in anxiety patients. However, hemostasis function has not yet been studied in patients with clinically relevant anxiety disorders.

Methods: A group of anxiety patients (panic disorder with agoraphobia or social phobia) and a healthy control group (each n = 29) completed some questionnaires [SCL-K9 (a short form of the SCL-90-R), State Trait Anxiety Inventory,
ADS (general depression scale)], and had blood drawn after a 15-min rest period. To assess the reaction of the hemostatic system by global entities, sum scores were computed from parameters of coagulation and fibrinolysis (fibrinogen, FVII,
FVIII, vWF, F1 + 2, TAT, D -dimer, 2 -AP, PAP, tPA, PAI-1). Interfering variables, such as age, gender, alcohol consumption and smoking status, were controlled.

Results: Anxiety patients scored higher in a composite hemostatic score and a sum score of fibrinolysis in comparison to the control group, with a predominant activation of inhibitors in fibrinolysis. However, the psychological variable with the closest association to hemostasis was not trait anxiety, but self-perceived worry about blood drawing before blood sampling was performed.

Conclusions: The coagulation and fibrinolysis system is activated in the direction of a hypercoagulable state in patients with severe phobic anxiety, triggered by
fear of blood drawing. This could be one mediating factor for the increased risk of cardiovascular diseases in this population. Acute situational phobic anxiety should be monitored closely when studying the association between anxiety and
hemostasis.

Authorized only

Cutt off points of waist circumference for defining abdomnial obesity in the Korean population, 2006 대한비만학회지

Background: Recently, the International Diabetes Federation (IDF) consensus proposed a new definition for diagnosing metabolic syndrome. Ethnic-specific waist circumference (WC) cut-off points have been incorporated into the definition. Therefore, the study of the WC cut-off points for defining abdominal obesity in Koreans was performed by the Korean Society of the Study of Obesity.

Methods: The data used for analysis was from the Korean National Health and Nutritional Examination Survey (KNHANES) performed in 1998 (involved 6562 participants), which is representative of nutritional health research in Korea. The 2005 International Diabetes Federation definition of the metabolic syndrome was applied. The reasonable cut-off points of WC for abdominal obesity in Koreans were set based on Receiver Operating Characteristics (ROC) curve, odds ratio and prevalence of abdominal obesity in the study population.

Results: Using ROC analysis, the optimal WC to predict the risk factors of metabolic syndrome, such as high triglyceride levels, low levels of HDL-cholesterol, hypertension, and high glucose levels in Koreans, was 82~84 cm for men, and 79~82 cm for women. The odds ratio of having more than 2 metabolic abnormalities was about 5 in men with WC > 90 cm and in women with WC > 80 cm. WC in the 80th percentile in the Korean population is 90 cm and 86.5 cm for men and women, respectively.

Conclusions: The cut-off points of WC for abdominal obesity in Koreans are 90 cm for men and 85 cm for women, respectively. The cut-off points of waist circumference for defining abdominal obesity should be followed up by future additional studies and updated when new data becomes available.
Authorized only

Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2005

This guideline is based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center. The American College of Physicians nominated this topic to the Agency for Healthcare Research and Quality Evidence-Based Practice Center program as part of a concerted effort to complement the guidelines of the U.S. Preventive Services Task Force. The College recommends that all clinicians refer to the Task Force recommendations as part of an overall strategy for managing overweight and obesity, which should always include appropriate diet and exercise for all patients who are overweight or obese. The intent of this guideline is to provide recommendations based on a review of the evidence on pharmacologic and surgical treatments of obesity. The target audience is all clinicians caring for obese patients, defined as a body mass index of 30 kg/m2 or greater. This guideline is not intended to be used by commercial weight loss centers or for direct-to-consumer marketing by manufacturers and does not apply to patients with body mass indices below 30 kg/m2.

Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2005

Treatment of obesity, 2004 Finnish Medical Society Duodecim

Treatment of obesity, 2004 Finnish Medical Society Duodecim (revised 2007)

Obesity: Assessment and Management in Primary Care - June 1, 2001 - American Family Physician

Obesity: Assessment and Management in Primary Care - June 1, 2001 - American Family Physician

The Clinical/Practical Guide : Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, NIH

Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report, 1998 NIH

The Practical Guide : Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 2000 NIH