Carotid Intima–Media Thickness for Cardiovascular Risk Assessment

September 5, 2012 | Harlan M. Krumholz, MD, SM | Cardiology

In a large meta-analysis, addition of the test did not substantially improve Framingham risk classification.

Reviewing: Den Ruijter HM et al. JAMA 2012 Aug 22/29; 308:796


Discussion on CardioExchange: Low-Dose Methotrexate to Prevent Recurrent MI and Stroke? Free!

September 5, 2012 | The Editors | Cardiology

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Patients Taking Antihypertensive Drugs Show Increase in Lip CancerFree!

August 30, 2012 | Craig A. Elmets, MD | Dermatology

Hydrochlorothiazide, HCTZ-triamterene, and nifedipine were associated with a higher incidence of lip cancer.

Reviewing: Friedman GD et al. Arch Intern Med 2012 Aug 6;


Lacunar Stroke Does Not Justify Long-Term Dual Antiplatelet Therapy

August 29, 2012 | Hooman Kamel, MD | Neurology

In the SPS3 trial, clopidogrel added to aspirin increased bleeding and mortality without providing a compensatory benefit.

Reviewing: The SPS3 Investigators. N Engl J Med 2012 Aug 30; 367:817


HAS-BLED for Assessing Bleeding Risk with Anticoagulation: Best of the Mediocre

August 22, 2012 | Mark S. Link, MD | Cardiology

Notwithstanding a lackluster performance, HAS-BLED beat two other scoring systems in a comparative analysis of trial data.

Reviewing: Apostolakis S et al. J Am Coll Cardiol 2012 Aug 28; 60:861


Anticoagulation for AF in Patients with Renal Disease: Between a Rock and a Hard Place

August 22, 2012 | Mark S. Link, MD | Cardiology

Patients with renal disease and AF have fewer strokes — but more bleeding — with warfarin treatment than without it.

Reviewing: Olesen JB et al. N Engl J Med 2012 Aug 16; 367:625


Does Invasive Therapy for AV Malformations Affect Seizure Rates?

August 21, 2012 | Seemant Chaturvedi, MD | Neurology

An observational study suggests no difference in seizure rates with invasive vs. conservative management of AVMs.

Reviewing: Josephson CB et al. Neurology 2012 Aug 7; 79:500


Restenosis Rates After Carotid Artery Stenting vs. Carotid Endarterectomy

August 21, 2012 | Hooman Kamel, MD | Neurology

Two-year follow-up of patients enrolled in the CREST trial shows that these procedures are equally durable.

Reviewing: Lal BK et al. Lancet Neurol 2012 Sep 11:755


Reducing Door-to-Needle Time for Treatment of Acute Stroke

August 17, 2012 | Richard D. Zane, MD, FAAEM | Emergency Medicine

Median door-to-treatment time dropped to 20 minutes after a series of process improvement measures were implemented at a single center in Helsinki.

Reviewing: Meretoja A et al. Neurology 2012 Jul 24; 79:306


Antenatal Stroke: What Do We Know About This Uncommon Event?

August 16, 2012 | Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC | Women’s Health

Histories of migraine, gestational diabetes, and hypertensive disorders are major risk factors.

Reviewing: Scott CA et al. Obstet Gynecol 2012 Aug 120:318


Betting on Intensive BP Reduction to Improve Outcomes After ICHFree!

August 14, 2012 | Hooman Kamel, MD | Neurology

An analysis of INTERACT1 raises the hope that intensive blood pressure reduction ultimately will be shown to improve clinical outcomes.

Reviewing: Delcourt C et al. Neurology 2012 Jul 24; 79:314


HIV-Positive Patients at Elevated Risk for Ischemic Stroke

August 13, 2012 | Carlos del Rio, MD | HIV/AIDS Clinical Care

The relative risk was greatest among women, patients younger than 50, and those with poor virologic control.

Reviewing: Chow FC et al. J Acquir Immune Defic Syndr 2012 Aug 1; 60:351

Endocrine Society Releases Guidelines on Managing Hypertriglyceridemia


The Endocrine Society has published new guidelines on diagnosing and managing hypertriglyceridemia in the Journal of Clinical Endocrinology and Metabolism.


Among the recommendations:

  • All adults should be screened for elevated triglyceride levels at least every 5 years as part of a lipid panel.
  • Diagnosis should be based on fasting triglyceride levels.
  • Medications and endocrine conditions should be ruled out as potential causes of elevated levels.
  • For patients with primary hypertriglyceridemia, clinicians should assess other cardiovascular risk factors and family history.
  • Mild-to-moderate hypertriglyceridemia (triglycerides of 150-999 mg/dL) should initially be managed with lifestyle therapy.
  • For patients with severe hypertriglyceridemia (1000 mg/dL or higher), a fibrate should be the first-line therapy.


Journal of Clinical Endocrinology and Metabolism article (Free abstract)

Dabigatran: How Safe?

Within 12 weeks of marketing approval, dabigatran was found to be responsible for more adverse events than nearly all other medications.


Dabigatran is an oral direct thrombin inhibitor that is approved for the prevention of stroke in patients with atrial fibrillation (JW Oncol Hematol Oct 6 2009). It is administered in a fixed dose (150 mg twice daily) and does not require monitoring, which are advantages over warfarin. However, recent data suggest that, compared with warfarin, dabigatran might be associated with more frequent serious adverse effects.

Now, an editorialist has reviewed reports of serious or fatal bleeding associated with dabigatran and found that, during the first 6 months of availability, the drug was responsible for 505 adverse events due to hemorrhage (including 65 deaths), compared with only 176 for warfarin. Some of these events were in patients who received the drug off label (for postoperative thromboprophylaxis) or with amiodarone (which potentiates its actions) or tissue plasminogen activator (which alters hemostasis). Nevertheless, within 12 weeks of initial marketing approval, dabigatran was reported to be responsible for more adverse events than 98.7% of all other medications.

Comment: The high number of adverse events with dabigatran might be due to several factors: lack of familiarity with the mechanism of action of the drug, administration of a dose that is too high for some patients (i.e., the elderly or those with comorbidities), treatment of conditions other than those that led to its approval, and lack of a readily available reversing agent. As with any new drug, physicians should carefully review prescribing information, closely monitor the patient, and be aware of possible adverse effects.

— David Green, MD, PhD

Published in Journal Watch Oncology and Hematology July 31, 2012


Radecki RP. Dabigatran: Uncharted waters and potential harms. Ann Intern Med  2012 Jul 3;  157:66.



Ginkgo Biloba: No-Go for Alzheimer’s Prevention


Another large trial shows no benefit from ginkgo biloba extract in preventing Alzheimer disease, researchers report in the Lancet Neurology.


Nearly 2900 older adults without dementia who spontaneously reported memory complaints to their physicians were randomized to consume standardized ginkgo biloba extract or placebo for 5 years. Overall, the rate of diagnosis with probable Alzheimer’s did not differ significantly between the ginkgo and placebo groups (1.2 and 1.4 cases per 100 person-years).


The authors note that a lower-than-expected Alzheimer’s rate in both groups reduced the study’s power, while a Lancet Neurology editorialist concludes: “For adults aged 70 years or older with a memory complaint who might be mildly cognitively impaired, use of [ginkgo biloba extract] does not decrease the risk of Alzheimer’s disease over 5 years.”


Lancet Neurology article (Free abstract)