Commentary

Aug 14, 2012

The Patient Protection and Affordable Care Act (PPACA but often called the ACA) was signed into law by President Barack Obama on March 23, 2010 after it passed both the House and Senate following 2 years of debate in Congress. On June 28, 2012, the US Supreme Court upheld the constitutionality of many of the most controversial provisions of the law – including the so-called “individual mandate” to purchase health insurance. The goal of the ACA is to improve access to care while lowering the...

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Jun 16, 2012

Blood pressure is known to follow a circadian rhythm in which the blood pressure falls by approximately 10% overnight. In many patients with hypertension (HTN) this drop in nocturnal blood pressure is blunted.  These patients are affectionately called “non-dippers.”  The non-dipping blood pressure pattern has been associated with a higher risk of cardiovascular events.  Several studies have evaluated the utility of changing blood pressure medication dosing times to bedtime.  ...

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Mar 29, 2012

Dronedarone (Multaq®), a guideline recommended drug therapy option for paroxysmal and persistent atrial fibrillation (AF), has failed to deliver on the initial hopes and hype as the safer alternative to amiodarone.  Recent studies have shown that dronedarone is associated with severe liver injury, pulmonary fibrosis, pneumonitis, as well as an increased risk of stroke and death.1-6 With the addition of a boxed warning prohibiting its use in patients with permanent AF, dronedarone...

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Mar 14, 2012

The American College of Chest Physicians Antithrombotic Guidelines, 9th edition are now available.  Here's a short summary about what every clinician should know.

2.   The Patient’s Opinion Matters.  Patient values and preferences regarding antithrombotic treatment vary.  Although the AT9 authors believe a reasonable trade-off between stroke and major bleeding events would be in the range of 2 or 3 to 1, they emphasize the need for shared decision making.2  This is...

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Feb 29, 2012

“See you in four weeks!” This has been a common ending to most anticoagulation clinic appointments over the years.  But perhaps it’s time for this routine to change?  A welcomed 12-week holiday may be coming for many patients based on evidence from a recent study as well as a new recommendation in the recently released 9th edition of the American College of Chest Physicians (ACCP)...

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Feb 3, 2012

Yet another clinical trial attempting to prove that adding a second lipid lowering agent to a statin-based regimen has failed. The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes (AIM-HIGH) trial prospectively compared cardiovascular (CV) event rates in statin treated patients with established atherosclerotic vascular disease who were randomized to...

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Jan 31, 2012

For diabetes patients uncontrolled on basal insulin therapy, is adding exenatide a good choice? Current treatment algorithms advocate for the addition of prandial insulin in patients who have not reached their glycemic targets with basal insulin.1 Exenatide is not FDA-approved for use in combination with basal insulin because current studies evaluating the combination of exenatide and...

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Jan 3, 2012

Should elderly patients with heart failure receive beta-blockers?  SENIORS — a parallel group, randomized, double-blind, multi-center trial comparing nebivolol to placebo — attempted to answer this question.1  Concern about the tolerability of beta-blockers in elderly patients persists despite some evidence that they are likely safe in older adults with heart failure (HF).2,3,4  The current American Heart Association (AHA) guidelines recommend that all clinically stable patients with HF and...

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Dec 16, 2011

Clinicians trying to make decisions based on the current best evidence are faced with an overwhelming obstacle, Too Much Information (TMI)! With over 25,000 new randomized controlled trials published each year how can a provider critically appraise these studies, determine their internal and external validity, put these results into context with what is already known, and then make an informed decision? Some of these data are biased and have uncertain value in...

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Oct 20, 2011

Do you tell your patients to take levothyroxine in the morning 30 to 60 minutes before food and at least 4 hours apart from other medications?  It is well known that many medications and foods influence the absorption and distribution of thyroxine (T4).  Morning administration of levothyroxine, before meals and other medications, is recommended by expert consensus and the package...

Comments: 2      Views: 8,117


Sep 29, 2011

The evidence regarding the benefits of statin therapy in patients with chronic kidney disease has been far from clear. There is no doubt that treatment of low density lipoprotein cholesterol (LDL-C) with statins reduces coronary events in many patient populations (average 20% reduction per 1 mmol/L LDL-C reduction or 38mg/dL).1 But previous trials in the end stage CKD population, two...

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Sep 8, 2011

The wait for alternatives to warfarin for stroke prevention in atrial fibrillation has been a long one. Patients and clinicians have long noted the limitations of warfarin, with dietary restrictions, drug-interactions and frequent monitoring.  Last year, dabigatran became available as an alternative based on the results of the RE-LY trial.1 Recently, the results of the ROCKET-AF trial...

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May 10, 2011

For patients with atrial fibrillation, what’s the best scoring system to estimate stroke risk? Clinicians have long relied on the CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes, and previous stroke or TIA] scoring system to make antithrombotic treatment decisions. The CHADS2 scoring system is validated and has good predictive value.1 Current treatment...

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May 3, 2011

Are you treating to an evidence-based blood pressure goal in patients with diabetes? Consensus guidelines suggest that we should aim for a blood pressure of < 130/80 mmHg.1,2 However, the support for this recommendation is derived from epidemiological data and subgroup analyses rather than well-designed, randomized controlled trials specifically designed to determine the optimal BP...

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Apr 26, 2011

Nearly two-thirds of all Americans diagnosed with high blood pressure are treated with medications - but fewer than half are controlled to their goal. And the rate of control is even lower in racial and ethnic minority subgroups.1,2  Patients who are younger, non-white, as well as those with asymptomatic chronic diseases and taking multiple daily medications have lower medication...

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Mar 16, 2011

Are all of your patients with symptomatic heart failure and a low ejection fraction receiving an aldosterone antagonist?  Why not?  Randomized, double-blind, multi-center clinical trials using aldosterone-receptor antagonists have demonstrated mortality benefits in patients with symptomatic heart failure when added to evidence-based therapy, including ACE-inhibitors.1,2,3  The recent...

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Feb 27, 2011

One in 3 adults in the United States have high blood pressure (HBP).1 That’s more than 74 million people!  From 1996 to 2006 the death rate due to HBP increased 19.5%. In those with hypertension, blood pressure (BP) control is poor.  In men, less than 40% are achieving their blood pressure goal.  In women, the percentage who are control is even worse.  In women age 60-79 years old only 28% are at their target BP and in women over 80 years old only 23% are at goal.2 Achieving a target BP is...

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Jan 13, 2011

Step one, short-acting beta agonists (SABA) as needed.  Step two: low dose inhaled corticosteroids (ICS). Step three, increase to medium dose ICS or add a long-acting beta agonist (LABA).  These are the preferred steps that are recommended by current asthma guidelines.1  But is there a better option for step three?  A recent double-blind, three-way, crossover trial set out to answer...

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Dec 7, 2010

If you are like me, you probably received a lot of phone calls from patients and prescribers when the news hit about the potential interaction between clopidogrel and proton pump inhibitors (PPIs).  In January 2009, the Food and Drug Administration (FDA) published data from an ongoing safety review of clopidogrel effectiveness, which resulted in a November 2009 Public Health Advisory that recommended avoiding of the combination of clopidogrel and any PPIs...

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Nov 4, 2010

Clinicians and patients alike have been anxiously waiting for an oral alternative to warfarin. That wait appears to be finally over. On October 19, 2010 dabigatran (Pradaxa®) was approved by the FDA and became the first oral direct thrombin inhibitor available in the United States. Unlike its predecessor ximelagatran, dabigatran doesn’t seem to cause liver toxicity. And unlike warfarin, dabigatran is administered as a fixed dose and requires no ongoing...

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Oct 18, 2010

Non-alcoholic fatty liver disease (NAFLD) is a condition characterized by fat deposition in the hepatocytes of patients with minimal or no alcohol intake.  NAFLD has emerged as the leading cause of chronic liver disease in the Western world, with an estimated prevalence of 20-30% in the general population.1  Patients with NAFLD may present along spectrum of histological findings, ranging from simple hepatic steatosis (fat accumulation without inflammation or fibrosis) to nonalcoholic...

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Mar 30, 2010

UPDATE:  See related story regarding editorial and open letter to NCEP ATP IV

I’ve long believed that statin therapy should be guided by a clinical risk assessment – not LDL cholesterol goals. None of the landmark clinical trials demonstrating the benefits of statin therapy have titrated the dose to an LDL goal. None. Participants were eligible for the studies based on clinical...

Comments: 2      Views: 9,532


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