An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Assessing cardiovascular risk one patient at a time.
J Fam Pract. 2009 Nov;58(11 Suppl Urgent):S26-31
Authors: Davidson MH
Given the Growing Prevalence of coronary heart disease (CHD) in the United States, risk assessment and reduction remain fundamental to family medicine practice. Risk assessment in cardiovascular disease is a constantly evolving field. The literature can be overwhelming; more than 4300 papers on the topic of CHD and risk were published in 2008 alone. Staying current with new, important developments in cardiovascular risk assessment clearly is challenging for most family physicians. Family physicians identify cardiac risk to prevent first cardiac events in their otherwise healthy patients and recurrent events in their patients with existing CHD. The first step in reaching primary prevention goals is to determine each individual patient’s 10-year risk of CHD. Risk assessment instruments traditionally have viewed low-density lipoprotein cholesterol (LDL-C) levels as a cornerstone of individual risk and a principal target for therapeutic intervention. Although risk assessment tools are helpful, many may not be useful to family physicians because they may be cumbersome, may measure individual risk components rather than global risk, and may require excessive time to complete. Nevertheless, some form of quantitative risk assessment is useful. Traditional global risk assessment instruments may underestimate risk, especially in asymptomatic patients with subclinical atherosclerosis. Emerging data about the role of biomarkers and the benefits of aggressive reduction in LDL-C suggest the need for a paradigm shift in risk attribution and intervention for primary care patients. Risk assessment strategies and new data about cardiovascular risk of interest to family physicians are presented here.
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– An urgent matter-identifying your patients’ cardiovascular risk and improving their outcomes. Assessing cardiovascular risk…
Rimonabant for prevention of cardiovascular events (CRESCENDO): a randomised, multicentre, placebo-controlled trial.
Lancet. 2010 Aug 14;376(9740):517-23
Authors: Topol EJ, Bousser MG, Fox KA, Creager MA, Despres JP, Easton JD, Hamm CW, Montalescot G, Steg PG, Pearson TA, Cohen E, Gaudin C, Job B, Murphy JH, Bhatt DL,
BACKGROUND: Blockade of the endocannabinoid receptor reduces obesity and improves metabolic abnormalities such as triglycerides, HDL cholesterol, and fasting blood glucose. We assessed whether rimonabant would improve major vascular event-free survival. METHODS: This double-blind, placebo-controlled trial was undertaken in 974 hospitals in 42 countries. 18,695 patients with previously manifest or increased risk of vascular disease were randomly assigned to receive either rimonabant 20 mg (n=9381) or matching placebo (n=9314). Randomisation was stratified by centre, implemented with an independent interactive voice response system, and all study personnel and participants were masked to group assignment. The primary endpoint was the composite of cardiovascular death, myocardial infarction, or stroke, as determined via central adjudication. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00263042. FINDINGS: At a mean follow-up of 13.8 months (95% CI 13.6-14.0), the trial was prematurely discontinued because of concerns by health regulatory authorities in three countries about suicide in individuals receiving rimonabant. All randomised participants were analysed. At the close of the trial (Nov 6, 2008), the composite primary endpoint of cardiovascular death, myocardial infarction, or stroke occurred in 364 (3.9%) patients assigned to rimonabant and 375 (4.0%) assigned to placebo (hazard ratio 0.97, 95% CI 0.84-1.12, p=0.68). With rimonabant, gastrointestinal (3038 [33%] vs 2084 [22%]), neuropsychiatric (3028 [32%] vs 1989 [21%]), and serious psychiatric side-effects (232 [2.5%] vs 120 [1.3%]) were significantly increased compared with placebo. Four patients in the rimonabant group and one in the placebo group committed suicide. INTERPRETATION: The premature termination of this trial has important lessons for drug development. A drug that was being marketed for weight loss, but being tested for improving cardiovascular outcomes, induced a level of serious neuropsychiatric effects that was deemed unacceptable by regulatory authorities, and both the drug and the trial were abruptly terminated. FUNDING: Sanofi-Aventis.
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– Rimonabant for prevention of cardiovascular events (CRESCENDO): a randomised, multicentre, placebo-controlled trial.
Practice implications of recent clinical trials for the prevention of acute kidney injury in cardiovascular surgery.
Hosp Pract (Minneap). 2010 Apr;38(2):67-73
Authors: Shimada M, Dass B, Dhatt GS, Alsabbagh MM, Asmar AR, Ather IM, Sharma R, Ejaz AA
Acute kidney injury in patients undergoing cardiovascular surgery is a complex problem with associated increased risks for dialysis, short- and long-term mortality, and progression to end-stage renal disease. Interventions to prevent and treat renal complications in this cohort have seldom been uniformly satisfactory due to the differences in strategies for intervention, drug doses and duration of treatment, baseline renal functions, and population studied. Nonetheless, significant advances have been made and include recognition of the effect of preexisting organ dysfunction on renal outcomes, reassessment of existing therapeutic interventions, and exploration of the feasibility of newer agents to prevent and treat acute kidney injury in cardiovascular surgery patients. This article briefly reviews several of these issues with an emphasis on recent clinical trials in this cohort.
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– Practice implications of recent clinical trials for the prevention of acute kidney injury in cardiovascular surgery.
