February 10th, 2014
Selections from Richard Lehman’s Literature Review: February 10th
Richard Lehman, BM, BCh, MRCGP
CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.
Lancet 8 Feb 2014 Vol 383 and NEJM 6 Feb 2014 Vol 370
Cobalt Intoxication Diagnosed with the Help of Dr. House (Lancet, pg. 574) and Missing Elements of the History (NEJM, pg. 559): At the opposite end of the medical spectrum from being a British GP is the acerbic American Dr Greg House (aka actor Hugh Laurie, son of an Oxford GP), whose diagnostic acumen makes up for his complete disregard for conventional ethics. A terrible role model, but he may have actually saved a life—for real. In one episode of House, the eventual diagnosis is cobalt poisoning, which causes heart failure. Ever heard of it? There are two reports of cobalt induced heart failure in this week’s journals, and in the Lancet case, it was a House watcher who made the connection between a dodgy hip replacement and the failing heart. Here in the NEJM, the diagnosis was only made after the patient had a heart transplant. There have probably already been thousands of cobalt related deaths in older patients with progressive heart failure of uncertain cause. From now on, cardiologists need to think cobalt in every heart failure patient with a metal hip prosthesis.
JAMA Intern Med Feb 2014
Transfer Rates From Nonprocedure Hospitals After Initial Admission and Outcomes Among Elderly Patients With Acute MI (pg. 213): Once again, the monthly journal floods us with an embarrassment of riches. I’m picking out this US study of transfer rates for myocardial infarct patients from non-PCI-providing hospitals to PCI-providers because (a) it shows wide and unaccountable variation in practice (b) it shows very little difference in outcomes according to rates of transfer and (c) I was at Yale when it was being done. It’s a typically high quality product from the Center for Outcomes Research and Evaluation. Conflict of interest statement: I love these guys and the work they do.
CABG vs. PCI and Long-term Mortality and Morbidity in Multivessel Disease (pg. 223):
“The time has come,” the Walrus said,
“To talk of many things:
Of shoes—and ships—and sealing-wax—
Of cabbages—and kings—
And why the sea is boiling hot—
And whether pigs have wings.”
There was a time when CABG was king: it was the most commonly performed major operation in the developed world. Then along came stents, and percutaneous coronary intervention developed wings. Boiling hot rows have ensued between surgeons and interventional cardiologists about how to interpret the sea of evidence. But the authors of this systematic review stamp their sealing wax down firmly in favour of CABG for 3+ vessel disease: “In patients with multivessel coronary disease, compared with PCI, CABG leads to an unequivocal reduction in long-term mortality and myocardial infarctions and to reductions in repeat revascularizations, regardless of whether patients are diabetic or not.”
PCI Outcomes in Patients With Stable Obstructive Coronary Artery Disease and MI (pg. 232): But does either of these cardiological pigs really have wings? The next systematic review looks at all randomized clinical trials of PCI and medical treatment vs MT alone for stable coronary artery disease in which stents and statins were used in more than 50% of patients. Their conclusion supports COURAGE: “In patients with stable CAD and objectively documented myocardial ischemia, PCI with MT was not associated with a reduction in death, nonfatal MI, unplanned revascularization, or angina compared with MT alone.”
JAMA 5 Feb 2014 Vol 311
Effects of Immediate BP Reduction on Death and Major Disability in Patients With Acute Ischemic Stroke (pg. 479): Most of this week’s JAMA is about high blood pressure. As we all know, long term BP and stroke risk show a nice linear relationship: and most of us in medicine, myself included, find comfort in simple things. It follows that a lot of patients who present with stroke also present with high blood pressure, and the temptation is to get it down as fast as possible. This idea was tested in 2038 patients admitted to Chinese hospitals: “Among patients with acute ischemic stroke, blood pressure reduction with antihypertensive medications, compared with the absence of hypertensive medication, did not reduce the likelihood of death and major disability at 14 days or hospital discharge.” BP lowering is a long-term strategy to prevent a second event, not an immediate necessity.
BP Trajectories in Early Adulthood and Subclinical Atherosclerosis in Middle Age (pg. 490): Blood pressure is an actual thing, but individual blood pressure measurements are a surrogate for what happens over decades within the circulation. Coronary artery calcium is also something real, but is just a distant surrogate for the thing that matters, which is unstable atheroma in the blood vessels supplying the myocardium. Marry up the two and you have a happy pair of surrogate parents: but what for? The trouble with blood pressure research is that it needs a decade or more to provide real knowledge about outcomes. This study identifies five trajectories of BP in younger adults, and links the higher ones with “subclinical atherosclerosis,” meaning a higher coronary calcium score. We get the drift: but how does this help us manage individual, perfectly asymptomatic, real people?
February 10th, 2014
FDA Reviewers Deliver Split Opinion on Cangrelor
Larry Husten, PHD
FDA reviewers presented two dramatically different views of The Medicines Company’s investigational new drug cangrelor. One reviewer says the drug should not be approved without a new trial and even states that the CHAMPION trials “were conducted unethically” and provide sufficient reason to “refuse approval…on that fact alone.” But two other reviewers recommend approval.
On Wednesday the FDA’s Cardiovascular and Renal Drugs Advisory Committee will meet to discuss two proposed indications for cangrelor. The first is for the reduction of thrombotic cardiovascular events including stent thrombosis in patients undergoing PCI. The second is for the maintenance of antiplatelet therapy in patients with acute coronary syndromes or patients with stents who have discontinued antiplatelet therapy because they are awaiting surgery and are at high risk for thrombotic events.
The negative perspective comes from the often outspoken and controversial FDA reviewer Tom Marciniak. (He has been a leading critic of rosiglitazone and rivaroxaban and has not hesitated in the past to disagree with fellow FDA staff members.) Marciniak maintains that the CHAMPION trials did not demonstrate that cangrelor was either superior or noninferior to clopidogrel in the CHAMPION trials. Some of his chief points are:
- Clopidogrel was not administered optimally (too late and with an inadequate loading dose) in the control arm.
- Much higher rates of bleeding in cangrelor patients.
- Cangrelor was better only in the subgroup of patients with stable angina.
- No comparison with the newer antiplatelet agents prasugrel or ticagrelor.
But two other FDA clinical reviewers deliver a more generous recommendation, though it may not inspire much confidence among the panel members. The reviewers note that the primary efficacy endpoint was “carefully crafted following post-hoc analyses” of two previous failed trials. Their recommendation appears based more on technical points than a view of the results as robust. For instance, they agree with Marciniak that fewer control patients received the higher 600 mg dose of clopidogrel, but don’t believe the results should be discounted because the higher dose is still not mandated by labeling or guidelines.
The negative viewpoint was also shared by the FDA statistical reviewer, who noted that after adjusting for the imbalance in the loading dose the primary endpoint would no longer be significant in favor of cangrelor.
Marciniak did not review the second bridging indication. The two other reviewers recommended a complete response letter due to the absence of clinical data supporting the indication.
In a second report, Marciniak argues that cangrelor should not be approved for ethical reasons because the clinical trials were imbalanced because clopidogrel was not used optimally. CHAMPION PHOENIX, he writes:
was unethical because it delayed use of clopidogrel until after coronary angiography or later and because it prohibited routine use of prasugrel, ticagrelor, and glycoprotein IIb/IIIa inhibitors (GPIs). The PHOENIX informed consent documents (ICDs) failed to inform patients regarding the advantages of earlier use of clopidogrel and the use of prasugrel, ticagrelor, and GPIs. The patients in PHOENIX were not informed about ‘appropriate alternative procedures or courses of treatment, if any, that might be advantageous to the subject’…”
February 6th, 2014
First-Ever Guidelines Issued on Stroke Prevention in Women
Nicholas Downing, MD
The American Heart Association and American Stroke Association have issued the first stroke-prevention guidelines that focus on women’s unique risks.
Among the recommendations:
- Pregnant women with chronic hypertension or a history of pregnancy-related hypertension should take low-dose aspirin, beginning at 12 weeks’ gestation, to reduce pre-eclampsia risk.
- Preeclampsia is a risk factor for stroke later in life, and other risk factors in such women should be treated early.
- Pregnant women with severe hypertension should receive antihypertensive therapy (e.g., methyldopa, labetalol); those with moderate hypertension (150-159 mm Hg/100-109 mm Hg) may be considered for treatment.
- Suspicion of cerebral venous thrombosis, more common in women, should warrant routine blood studies: complete blood count, chemistry panel, prothrombin time, and activated partial thromboplastin time.
Hooman Kamel, a neurologist with NEJM Journal Watch, notes that, “Certain stroke risk factors are unique to women or occur more commonly in women. To help better address these gender-specific risk factors, the American Heart Association/American Stroke Association have just released a first-ever set of guidelines for the prevention of stroke in women. To be effective, many of these recommendations will require diffusion into routine primary care practice: for example, pulse screening for atrial fibrillation, or flagging patients with pre-eclampsia or eclampsia for close monitoring of blood pressure after pregnancy. Other recommendations provide a practical guide for stroke specialists: for example, guidelines on the evaluation and treatment of cerebral venous thrombosis, which occurs much more commonly in women. It is to be hoped that more tailored treatment of these gender-specific risk factors will ultimately reduce the overall burden of stroke.”
February 6th, 2014
Scrutinizing the ESC Position Paper on Radiation Safety in Cardiovascular Imaging
Reza Fazel, MD, MSc
The European Society of Cardiology (ESC) recently released a position paper on radiation safety in cardiovascular imaging. Here is the paper’s stated objective:
[to] provide a European perspective on the best way to play an active role in implementing in clinical practice the key principle of radiation protection that: ‘each patient should get the right imaging exam, at the right time, with the right radiation dose’.
Clearly written and highly readable, the paper touches broadly on key issues related to radiation safety, including the principles of justification (ensuring that imaging studies are clinically necessary and appropriate) and optimization (ensuring that imaging is performed in the safest manner). However, the paper is strikingly lacking in specific and implementable recommendations and, as such, seems to fall short of its stated objective. It clearly communicates the need for improving radiation safety in cardiovascular imaging but does little to help us understand how we can do that.
For example, the document advocates for justification — a key principle of radiation safety — but does not set forth an action plan for promoting it. How do we monitor appropriateness of imaging studies? How do we reduce the number of inappropriate studies? What are the barriers to using tools such as the Appropriate Use Criteria (AUC) for this purpose, and how can those barriers be overcome? While there is scant evidence in the literature to help answer these difficult questions, an attempt to address these issues would have been useful, particularly given the breadth of expertise among the document authors.
Similarly, the document briefly mentions a few optimization techniques for nuclear cardiology and cardiac CT but does not discuss practical strategies to promote their widespread adoption by imaging labs. How should performance of imaging labs be monitored? How do we address the lack of diagnostic reference levels for most types of cardiac imaging with ionizing radiation?
As another example, the paper highlights the knowledge gap among clinicians regarding typical doses for cardiac imaging studies and the risk attributable to those doses. It is suggested that requiring discussion of radiation-related risks as part of informed consent will force clinicians to bridge that knowledge gap. Although there is truth in this statement, the strategy does not seem to be adequate for addressing the problem systematically.
Some inaccurate statements in the paper are also troubling. For example, it states, “at least one-third of all cardiac examinations are partially or totally inappropriate.” First, the percentages of inappropriate studies in the cited study were actually 14% and 18% for stress echo and SPECT, respectively. Characterizing the uncertain category in AUC as “partially inappropriate” is incorrect and not consistent with its definition. Furthermore, it is unclear how the authors’ inference about all cardiac imaging is justified on the basis of data from a relatively small study of two imaging modalities from a single institution.
More important, some of the cancer-risk estimates listed in the paper are controversial, including those quoted for interventional cardiologists and children with congenital heart disease. The cited studies do not use the preferred method of cancer-risk estimation, which involves calculation of organ doses, applying tissue weighting factors, and then applying age- and sex-specific risk coefficients from the BEIR VII report. Rather, those studies derived risk estimates based on effective doses, which is beyond the intended scope of the effective-dose concept and is not scientifically valid. Effective dose should not be used for epidemiologic studies or to estimate population risks, given the inherent uncertainties and oversimplifications (Martin et al., Br J Radiol 2007; 80:639; McCullough et al., AJR 2010; 194:890).
Finally, the paper makes no substantial mention of the European experience. Discussing success stories from Europe and approaches that European centers have taken to improve radiation safety would have been very helpful.
Overall, considering the large audience that any ESC document will reach, I believe this paper will significantly raise general awareness of radiation safety among cardiologists and other clinicians. In some ways, though, it is also a missed opportunity to influence clinical practice more meaningfully.
If you have a chance to read the document, please share your thoughts: Does it give you new insights about radiation safety? Will it influence your clinical decision-making? If so, how?
February 6th, 2014
Carotid IMT Testing: Misgraded and Misunderstood
James H Stein, MD and Matthew C Tattersall, DO
The 2013 American College of Cardiology American Heart Association Guideline on the Assessment of Cardiovascular Risk has generated a lot of discussion about the accuracy and validity of the pooled risk prediction equations. Lost in the heat generated by that discussion, however, is a controversial Class III recommendation for common carotid artery intima-media thickness (CCA IMT) testing, which, essentially, recommends against its use. Yet, just three years ago, the ACC/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults gave it a class IIa recommendation — saying it was “reasonable” if published technical standards were followed, as is recommended for coronary artery calcium screening (CAC). This major downgrade was a surprise, because no new, guideline-modifying data about the predictive value of CCA IMT testing was published in the interim.
We think this downgrade is the result of two separate, but related, problems.
First, the 2010 guideline gave too high a rating to both CCA IMT and CAC — the IIa grade was undeserved, because no data at that time, or even at present, suggest major improvements in patient outcomes using either imaging test. The misrepresentation in the recent ACC/AHA guideline, however, seems to result from a misunderstanding of how CCA IMT testing is used clinically, which leads to the second problem.
The description of CCA IMT testing in the ACC/AHA Guideline focuses on its weak predictive characteristics, and references a meta-analysis by Den Ruiter et al that focused on CCA IMT from many population-based studies. However, the American Society of Echocardiography (ASE) Consensus Statement on carotid ultrasound for cardiovascular disease (CVD) risk prediction and others have specified that carotid ultrasound for CVD risk prediction should be based on a thorough scan of the carotid arteries for the presence of plaques in addition to measurement of CCA IMT. This is because the presence and extent of carotid plaque, which occurs predominantly in the carotid bifurcation and internal carotid artery, rather than the CCA, are independent predictors of future CVD events and in observational studies perform better than CCA IMT alone.
The ASE Consensus Statement, which has been widely adopted, specifically stipulated that measuring CCA IMT without considering plaque presence was insufficient; however the study that provided the recent ACC/AHA Working Group with the strongest evidence for its class III recommendation was a meta-analysis based solely on CCA IMT without regard to plaques. The ACC/AHA Working group raised important concerns about standardization and measurement issues, however, clinical use of this carotid ultrasound for CVD risk prediction has been standardized for over five years. It has published appropriate use criteria and its reproducibility is excellent, even in less experienced hands.
We believe that a Class IIb recommendation would be more appropriate, based on the test characteristics of CCA IMT plus plaque scanning. Although CAC appears to be a better predictor of CVD than CCA IMT and plaques in many (though not all) studies, neither CAC nor CCA IMT have been demonstrated to improve patient outcomes. The best either test has shown is modest improvements in risk factors, use of statins and aspirin, and patient and physician intentions.
February 5th, 2014
Eric Topol to Be AT&T’s Chief Medical Advisor
Larry Husten, PHD
AT&T announced today that it has appointed cardiologist Eric Topol as its Chief Medical Advisor. The company said he will “impact the design, development and delivery of AT&T’s healthcare IT solutions, connecting the healthcare ecosystem to enhance health outcomes and care delivery processes for patients and their caregivers.”
In addition to his duties at AT&T, Topol will continue to serve as the the Chief Academic Officer at Scripps Health and as the editor-in-chief of Medscape. He is the author of The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Before moving to Scripps, Topol had been the chairman of cardiovascular medicine at the Cleveland Clinic. Topol, along with Robert Califf, was the leading force behind the highly influential GUSTO trials and their predecessor, the TAMI trials.
“Dr. Topol is a change agent who has dedicated his career to creating awareness and promoting adoption of health IT solutions to improve patient care,” said an AT&T senior vice president, in a press release. “Enlisting Dr. Topol into our AT&T ForHealth program will help us drive our competitive strategy as we focus on innovative solutions powered by our network.”
Said Topol: “With connected devices, the flow of health and medical information is going through a radical change, which puts patients in an exceptionally powerful and important position. I’m honored to work with AT&T as we seek to develop new solutions that will change the trajectory of digital health and impact patient outcomes.”
February 5th, 2014
The Value of Imaging Atrial Tissue Fibrosis in Patients Who Undergo Catheter Ablation for Atrial Fibrillation
Nassir F. Marrouche, MD
CardioExchange’s John Ryan interviews Nassir F. Marrouche, lead author of the DECAAF study, about the use of delayed-enhancement MRI to identify atrial tissue fibrosis in patients who undergo catheter ablation for atrial fibrillation. The study is published in JAMA.
THE STUDY
Researchers prospectively enrolled 329 patients diagnosed with atrial fibrillation who were scheduled to undergo their first catheter ablation procedure at one of 15 centers in the U.S., Europe, and Australia. Delayed-enhancement MRI was performed within 30 days before ablation. Fibrosis was categorized as stage 1 (<10% of the atrial wall), stage 2 (10–<20%), stage 3 (20–<30%), or stage 4 (≥30%). Results in 260 patients with good-quality MRI images and available follow-up data showed significantly elevated risk for recurrent arrhythmia per 1% increase in left atrial fibrosis. Adding fibrosis to a traditional prediction model improved the accuracy of predicting recurrence.
THE INTERVIEW
Ryan: Given your data, if patients have stage 4 atrial fibrosis, they have about a 70% chance of recurrence of atrial fibrillation. Should we even be offering these patients catheter ablation?
Marrouche: Patients with advanced atrial fibrotic disease (stage IV and diffuse stage III) continue to be a challenge for the physician who performs ablations. We and others are studying alternative options for this patient population.
Ryan: How reproducible are the MRIs between centers? Can — and should — this practice be introduced on a larger scale? How many patients are likely not to be candidates for cardiac MRI because they already have devices that preclude the scan?
Marrouche: In DECAAF, the reproducibility of “fibrosis-specific” MRI sequences/acquisition was excellent. Centers went through a 3- to 4-scan learning phase, but acquisition was perfected with training. All MRI scanners can be equipped with the fibrosis-specific sequence. With the introduction of new MRI-compatible pacemakers and defibrillators, scanning these patients’ hearts should no longer be a challenge.
Ryan: Can the location of atrial fibrosis guide the ablation technique?
Marrouche: Indeed, the DECCAF subanalysis presented at the ESC conference in Amsterdam revealed that ablation-induced scarring that covers fibrosis would improve procedural outcomes. We and others are studying this prospectively.
Ryan: Is there a difference in clinical outcomes such as stroke, heart failure, and hospitalization, depending on the stage of atrial fibrosis?
Marrouche: Multiple studies published in the past 5 years correlate atrial fibrosis with stroke risk, left-atrial-appendage clot formation, and heart failure. Atrial fibrosis can be considered in assessing the risks for stroke and heart failure in arrhythmia patients and, possibly, also in high-risk patients who have no history of arrhythmia.
Given the findings of Dr. Marrouche and his colleagues, would you favor the use of delayed enhancement MRI to detect atrial tissue fibrosis in this population?
February 4th, 2014
Blood Pressure Trajectory Over 25 Years Predicts Atherosclerosis Risk
Larry Husten, PHD
Everyone knows that blood pressure is one of the most important measurements of cardiovascular risk. Less well known is that most studies of blood pressure have relied on single or isolated measurements of blood pressure. Few studies have even attempted to examine the significance of blood pressure patterns over a long period of time.
Now, in a paper published in JAMA, researchers present an analysis of data from 3442 adults who participated in the long-term CARDIA study. Study participants were 18-30 years of age at baseline and had multiple blood pressure measurements over the course of the study. After 25 years, they had a CT scan that measured their coronary artery calcium (CAC) score. A CAC score of 100 or greater was considered to be evidence of subclinical atherosclerosis. (Although many doubts have been expressed about the role of the CAC score in contemporary medicine, its use as a marker for subclinical atherosclerosis in a study of this sort is probably not controversial. Because of the young age of the participants at the start of the study, the investigators were unable to study differences in actual cardiovascular events.)
The researchers identified five distinct patterns of blood pressure over time:
- 21.8% of the patients had low blood pressure throughout the study (low-stable). 4% of people in this group had evidence of atherosclerosis on their calcium scan after 25 years.
- 42.3% had moderate blood pressure levels throughout the study (moderate-stable). 7.9% of people in this group had atherosclerosis.
- 12.2% had moderate blood pressure at the start and then had a rapid increase in blood pressure (moderate-increasing). 10.1% of people in this group had atherosclerosis.
- 19.0% had relatively elevated blood pressure levels throughout the study (elevated-stable). 17.4% of people in this group had atherosclerosis.
- 4.8% had high blood pressure throughout the study (elevated- increasing). 25.4% of people in this group had atherosclerosis.
After adjustment for other differences in risk factors between the groups, people in the elevated-increasing group were 3- to 4-times more likely to have atherosclerosis than those in the low-stable group. The investigators note that most of the participants with elevated blood pressures during the study did not meet the definition for actual hypertension but fell within the range of prehypertension (generally defined as a blood pressure between 120/80 mm Hg and 139/89 mm Hg). African-Americans and smokers were more likely to have a rapid increase in blood pressure in middle age.
The authors conclude that their “findings suggest that an individual’s long-term patterns of change in BP starting in early adulthood may provide additional information about his or her risk of development of coronary calcium. In particular, prehypertension at a young age followed by long-term exposure to BP levels in the prehypertension range or higher was strongly associated with a CAC score of 100 HU or greater.”
February 3rd, 2014
Intensive BP, Lipid Lowering Does Not Protect Against Cognitive Decline in Diabetics
Nicholas Downing, MD
Intensive treatment of blood pressure or cholesterol does not slow the rate of cognitive decline in adults with type 2 diabetes, according to a substudy of the ACCORD trial published in JAMA Internal Medicine.
Some 3000 older adults with poorly controlled diabetes, high cardiovascular risk, and no evidence of cognitive impairment were assigned to one of two study arms: in one, participants were randomized to either intensive BP lowering (systolic goal, <120 mm Hg) or standard BP therapy (goal, <140 mm Hg); in the other, participants with LDL levels controlled below 100 mg/dL on simvastatin were randomized to either additional therapy with fenofibrate or placebo.
At 40 months, cognitive scores had decreased in all groups, with no difference between intensive and standard BP treatment nor between fibrate and placebo.
The researchers conclude that these results, along with previous ACCORD findings, “make clear the decreasing returns of intensive medication-based therapy” for advanced type 2 diabetes.
February 3rd, 2014
The Not So Sweet Facts About Sugar
Larry Husten, PHD
A new study offers a broad overview of the use of sugar in the U.S. diet and its consequent health implications. The good news is that the growth in sugar intake appears to have stopped and may even have slightly declined. The bad news is that people still consume way too much sugar and that sugar is killing them.
In a paper published in JAMA Internal Medicine, Quanhe Yang, from the Centers for Disease Control and Prevention, and colleagues analyze data about sugar use and its health effects from the NHANES (National Health and Nutrition Examination Survey) studies. They report that the percentage of daily calories from added sugar grew from 15.7% in 1988-1994 to 16.8% in 1999 to 2004 but then fell back to 14.9% in 2005-2010.
But more than 7 out of 10 adults in the U.S. (71.4%) get more than 10% of their calories from added sugar, while 1 out of 10 get a full 25% of their calories from added sugar. (The Institute of Medicine recommends that added sugar compose less than 25% of total calories; the World Health Organization recommends a much lower 10%. The American Heart Association doesn’t recommend a specific percentage but their recommendations translate into even lower percentages of added sugar.)
The authors found a strong association between the amount of added sugar in the diet and cardiovascular mortality. The association persisted even after adjusting for other known risk factors. The authors estimated that people who consumed between 10% and 25% of their calories from added sugar had a 30% increase in cardiovascular mortality. For people who consumed more than 25% of their calories from added sugar the risk nearly tripled (adjusted HR 2.75).
In an invited commentary, Laura Schmidt writes that sugar used to be viewed benignly as a vehicle for empty calories. Its associated ill effects were because the sugar was “a marker for unhealthy diet or obesity.” But now a “new paradigm” has emerged in which sugar is an independent risk factor for cardiovascular disease and other diseases:
The new paradigm hypothesizes that sugar has adverse health effects above any purported role as ’empty calories’ promoting obesity. Too much sugar does not just make us fat; it can also make us sick.”
NEJM Journal Watch — Recent Cardiology Articles- New Recommendations for Lipid Management in Patients with Acute Coronary Syndromes
- Postpartum Blood Pressure Control in Hypertensive Disorders of Pregnancy: Is Lower Better?
- Beta-Blocker Use After Takotsubo Syndrome
- CTA-Guided Care in Stable Angina: Long-Term Results
- Patients Need Standardized Education for Accurate Home Blood Pressure Monitoring