RxPG News : Stroke

New device performs better than old for removing blood clots

Fri, 03 Feb 2012 05:00:00 PST

( from http://www.rxpgnews.com ) An experimental blood clot-removing device outperformed the FDA-approved MERCI; retriever device, according to late-breaking science presented at the American Stroke Association's 2012 International Stroke Conference.

The SOLITAIRE; Flow Restoration Device is a self-expanding stent-based design that mechanically removes blood clots from blocked vessels after a stroke. After insertion into the clot using a thin tube, or catheter, the device traps the clot then both device and clot are removed, restoring blood flow. The MERCI retriever uses a tiny corkscrew, guided by a balloon-tipped wire, to snare and remove the blood clot.

In the Solitaire With the Intention for Thrombectomy (SWIFT) trial, the first U.S. clinical trial to compare the two devices, 113 stroke patients at 18 hospitals were randomly assigned to undergo clot removal with either device within eight hours of stroke onset between Feb. 2010-Feb. 2011.

The trial was ended at the suggestion of a safety monitoring committee nearly a year earlier than planned due to significantly better outcomes with the new device. The experimental device opened blocked vessels without causing symptomatic intracranial hemorrhage in 61 percent of patients. The currently approved device had the same result in 24 percent of cases - a statistically significant difference, said Jeffrey L. Saver, M.D., lead author of the study, professor of neurology and director of the Stroke Center in the Geffen School of Medicine at the University of California in Los Angeles.

The use of the new device also led to better survival three months after stroke. There was a 17.2 percent mortality rate with the new device versus 38.2 percent with the older one.

Stroke caused by a blood clot blocking a blood vessel supplying the brain is the most common type of stroke, accounting for about 87 percent of all strokes. The FDA-approved treatment for stroke with the most robust body of evidence is use of a clot-busting drug, but the drug must be given within 4.5 hours of symptom onset, and more quickly in older patients. When clot-busting drugs cannot be used or are ineffective, the clot can sometimes be mechanically removed, during or even after the 4.5 hours. The study didn't compare mechanical clot removal to drug treatment.

Although not yet approved in the United States, the new device is approved in Europe.

Other specific findings - all of which were statistically significant - were:

Two percent of SOLITAIRE-treated patients had symptoms of bleeding in the brain compared to 11 percent of MERCI patients.

At the 90-day follow-up, overall adverse event rates, including bleeding in the brain, were similar for the two devices.

Fifty-eight percent of SOLITAIRE-treated patients had good mental/motor functioning at 90 days compared to 33 percent of MERCI patients.

The SOLITAIRE device also opened more vessels when used as the first treatment approach, necessitating fewer subsequent attempts with other devices or drugs.

Patients' average age was 67 years and 68 percent were male. Forty percent had not improved with standard clot-busting medication prior to the study, while the remainder had not received it.

The time from the start of symptoms to start of the clot retriever treatment was on average 4.9 hours for SOLITAIRE and 5.3 hours for MERCI. The study results account for this time difference.

This heralds a new era in acute stroke care, said Saver. We're going from our first generation of recanalization procedures, which were only moderately good in reopening target arteries, to now having a highly effective recanalization device. This really is a game-changing result.

Cardiovascular Nursing Spring Meeting

Thu, 02 Feb 2012 05:00:00 PST

( from http://www.rxpgnews.com ) New scientific findings and hot topics in cardiovascular nursing will be the focus of the 12th Annual Spring Meeting on Cardiovascular Nursing. Managing in today's challenging financial environment and dealing with the increasing issue of cardiovascular disease in dementia patients are just two items on the packed agenda.

Some 200 abstracts will be presented by nurses and allied professionals on a wide range of topics including arrhythmias, heart failure, prevention, acute care, myocardial infarction and implantable devices. There's such a breadth of research and quality improvement projects that nurses and AHPs (allied health professionals) bring to this congress, says Professor Christi Deaton, immediate past-chairperson of the Council on Cardiovascular Nursing and Allied Professions (CCNAP).

This year's meeting, 'Health at Heart', is organised jointly by the (CCNAP) of the European Society of Cardiology (ESC) and the Professional Society for Cardiovascular and Thorax Surgery Nurses, based in Denmark. It will be held 16-17 March 2012 at the state of the art Bella Centre in Copenhagen, Denmark.

New scientific findings will be presented on risky behaviours in adolescents with congenital heart disease, the links between depression and heart disease, the impact of art on quality of life in stroke survivors, and numerous other subjects of interest to journalists and the wider public.

This year will see a record number of moderated posters presented, a great opportunity for journalists to get stories and speak to the researchers. We increased the number of moderated poster sessions because it was such a popular forum last year, says Dr Kaat Siebens, chairperson of the CCNAP. It was an excellent opportunity to see the posters up close and have a good discussion with the scientists.

In addition to the abstracts, sessions will be held on hot topics in cardiovascular nursing that affect large numbers of patients. A session on fear in cardiovascular patients will consider whether fear is a positive coping strategy or negative emotional status, how fear can lead to delays in seeking treatment, and the relationship between fear and inflammation, which is associated with worse outcomes. Another session will explore the growing problem of how to manage complex cardiovascular problems in older patients with dementia.

A session will be devoted to leadership and management in difficult times, including how to get nurse-patient ratios right and how to motivate and retain experienced nurses. This is particularly newsworthy given today's financial climate. We are in difficult financial times and that affects healthcare, says Professor Deaton. Oftentimes healthcare systems decrease staffing when there is an economic crisis.

For the first time a daily congress news will be distributed which highlights events not to be missed by delegates and the press, and the day's top three abstracts (oral, moderated poster, and poster), chosen by the CCNAP and dubbed the 'Reviewers Choice'.

Also new will be on-site interviews with key figures, including a nurse prescriber who can discuss this important subject ahead of the 2013 meeting in Glasgow, where nurses can prescribe.

The meeting attracts around 600 nurses, allied professionals and technicians from Europe and beyond. Delegates and journalists will stay at the striking Bella Sky Comwell Hotel, which is attached to the congress centre. For those who wish to visit the city centre, Copenhagen Central Station is just 10-15 minutes' drive away.

We drafted the scientific programme with topics that are really important for our delegates, concludes Dr Siebens. And everybody is feeling the crisis, so I think one of the most important sessions will be the one regarding leadership and management in difficult times.

Clot-busting drugs appear safe for treating 'wake-up' stroke patients

Wed, 01 Feb 2012 05:00:00 PST

( from http://www.rxpgnews.com ) Clot-busting drugs may be safe for patients who wake up experiencing stroke symptoms, according to preliminary research presented at the American Stroke Association's International Stroke Conference 2012.

In wake-up stroke, the person wakes up with symptoms after going to sleep with none. Not knowing when the stroke began excludes these patients from anti-clotting drugs that must be given within 4.5 hours of the beginning of the stroke.

Because wake-up strokes are common, occurring in up to a quarter of stroke sufferers, more research is needed on how to treat these patients, said Dulka Manawadu, M.D., lead researcher and a stroke medical consultant at King's College Hospital in London, U.K. Patients who experience stroke symptoms should call Emergency Medical Services urgently and get to the hospital fast, regardless of the time of onset. This will help specialists decide if novel interventions are appropriate and feasible.

In the study, researchers used a stroke registry to compare clot busting treatments received by 326 patients within 4.5 hours of symptom onset to 68 wake-up stroke patients, with unknown onset.

All the patients were treated in the same London medical center, where 20 percent suffered wake-up stroke. Researchers didn't randomly assign patients to receive different treatments for comparison, which is the gold standard and, thus, a limitation of the study.

Our study shows that administering clot-busting drugs to patients with wake-up stroke who have the same clinical and imaging features as those treated within current guidelines is feasible and safe, Manawadu said.

Researchers analyzed information on patients who received the clot-buster alteplase, sold under the name Activase, between January 2009 and December 2010. Wake-up stroke patients received clot-busting treatments if their clinical presentation and early stroke changes on CT scan images were comparable to those treated with a known time of onset. Both groups had similar blood pressure, blood sugar levels and scores on the National Institutes of Health Stroke Scale, which is a standardized method used by healthcare professionals to measure the level of impairment caused by a stroke.

After three months, the researchers found the wake-up stroke patients' death rates, risk of bleeding inside the brain, and the proportion that made a good recovery were similar to those patients treated within a known 4.5 hours of stroke onset.

Sometimes, doctors are reluctant to give clot-busting drugs to patients in whom the time of stroke onset is not known, because the risks of bleeding are not known, Manawadu said. However, a significant proportion of patients who have stroke symptoms on waking may have suffered stroke in the early hours of the morning and may still be within the window of time where clot-busting treatments are known to be effective. It is also likely that advanced imaging techniques may help to identify patients with wake-up stroke who have the potential to benefit from clot-busting drugs.

This is an area of growing importance because it may allow us to extend the indication for this effective treatment, Manawadu said. Research has been limited to date but the time is ripe to investigate effective treatments in this group of patients.

Infections in childhood linked to high risk of ischemic stroke

Wed, 01 Feb 2012 05:00:00 PST

( from http://www.rxpgnews.com ) Common infections in children pose a high risk of ischemic stroke, according to research presented at the American Stroke Association's International Stroke Conference 2012.

In a review of 2.5 million children, the researchers identified 126 childhood ischemic stroke cases and then randomly selected 378 age-matched controls from the remaining children without stroke. They discovered that 29 percent of those who suffered a stroke had a medical encounter for infection in the two days preceding the stroke versus one percent of controls during the same dates.

In the three- to seven-day window, 13 percent of children had an infection compared to 2 percent of controls.

The elevated risk of stroke didn't persist after the first month of infection, researchers said.

This is the first large study to establish the relationship between infection and stroke in children, said Heather Fullerton, M.D., the study's principal investigator and director of the Pediatric Stroke and Cerebrovascular Disease Center at the University of California in San Francisco.

Researchers analyzed diagnostic and radiologic databases of children enrolled in the Kaiser Permanente healthcare plan from 1993 to 2007. They evaluated medical records and chart reviews for infections during the two years prior to the childhood stroke, and the same time period for the age-matched controls.

The children with stroke ranged from infants to adolescents, average 10.5 years old (oldest child was 19). Researchers identified three stroke-free controls per case. Findings between girls and boys or ethnic groups didn't differ.

Researchers found acute infections are more important in triggering stroke than chronic infections over time.

These were predominantly minor acute infections and represented a variety of infections, including upper respiratory infections, urinary tract infections and ear infections, Fullerton said. No particular type of infection predominated.

The study findings hold implications for the secondary prevention of stroke in children, she said.

Most previously healthy children with an ischemic stroke have a disease of the blood vessels to the brain, and these children are at highest risk of recurrent stroke. This study may provide some insight into why children develop this arteriopathy: the inflammatory process that results from an infection which may lead to stroke by causing vascular injury, researchers said.

The standard treatment for ischemic stroke in children is blood thinners. But the study suggests that future research should focus on the potential role for anti-inflammatory medications in preventing the recurrence of stroke in this population.

The incidence of stroke in childhood is about five per 100,000 in the United States each year, Fullerton said.

About half of childhood strokes are hemorrhagic (bleeding in the brain), according to American Heart Association statistics.

Childhood infections are exceedingly common, while childhood strokes are uncommon, Fullerton said. Parents should not be alarmed at the findings of this study. We suspect that there are rare genetic factors that may place some children at risk for this uncommon effect of common infections.

Infection is an established risk factor for ischemic stroke in adults. In the United States, stroke is the fourth leading cause of death and a leading cause of serious disability among adults.

Canada's first renal denervation procedure to reduce high blood pressure performed today

Tue, 17 Jan 2012 05:00:00 PST

( from http://www.rxpgnews.com ) Doctors at the Peter Munk Cardiac Centre today performed a minimally invasive surgical procedure to treat high blood pressure, called renal denervation, for the first time in Canada. The procedure can significantly reduce high blood pressure in patients who cannot effectively treat their hypertension through drugs. These patients, numbering approximately 250,000 Canadians, have to endure an especially high risk of heart attacks and stroke, which continues to kill thousands of Canadians every year.

The first Canadian patient to undergo renal denervation, a 57-year-old male from Toronto, will be discharged tomorrow after overnight observation. The procedure was performed by a multi-disciplinary team, led by Dr. Dheeraj Rajan, Interventional Radiology Specialist; Dr. Douglas Ing, Cardiologist and Dr. George Oreopoulos, Vascular Surgeon. The team recently returned from Germany, where they trained for the procedure. Germany has approved the use of renal denervation to treat selected patients with hypertension.

The Peter Munk Cardiac Centre was the first centre in Canada to receive approval for renal denervation from Health Canada under the Special Access Program that allows practitioners to request access to procedures or drugs that are currently not otherwise approved for use in Canada. As the Health Canada web site notes: This access is limited to patients with serious or life-threatening conditions on a compassionate or emergency basis when conventional therapies have failed, are unsuitable, or are unavailable.

Said Dr. Barry Rubin, Medical Director at the Peter Munk Cardiac Centre: Decreasing a patient's systolic blood pressure from 160 to 130 mm Hg over a period of six months, which this procedure has been shown to do, could prevent many heart attacks and strokes from ever happening.

In addition, renal denervation could also save the health care system countless millions of dollars by minimizing the need for anti-hypertension drugs that patients have to take, often for the rest of their lives, to say nothing of the millions more in savings from not having to treat heart attacks and strokes that don't happen.

The procedure was first used in patients in Melbourne, Australia, and its effects were reported in a clinical trial published in the December 4, 2010 issue of The Lancet. This trial saw cardiologists from Australia, New Zealand, the United Kingdom and several European countries de-activate the nerves located on the outside of the artery that feeds blood to the kidney, with a resulting drop in blood pressure. It has been known for over 50 years that the kidney plays a defining role in determining blood pressure.

Said Dr. Rubin: Our multidisciplinary renal denervation program, which also includes hypertension and kidney specialists, will treat many more patients with hypertension in the months ahead. Our focus will be directed at studying the safety and efficacy of the procedure, which could also have important secondary benefits. For example, many Canadians with heart failure have high blood pressure. Using renal denervation to treat high blood pressure in these patients could improve heart failure, a major cause of death of Canadians.

New predictor of heart attack or stroke

Mon, 19 Dec 2011 05:00:00 PST

( from http://www.rxpgnews.com ) CHICAGO --- A hike in your blood pressure during middle age significantly raises the risk of having a heart attack or a stroke during your lifetime, according to new Northwestern Medicine research. The study offers a new understanding on the importance of maintaining low blood pressure early in middle age to prevent heart disease later in life.

Men and women who developed high blood pressure in middle age or who started out with high blood pressure had an estimated 30 percent increased risk of having a heart attack or stroke compared to those who kept their blood pressure low.

Previous estimates of a person's risk of cardiovascular disease were based on a single blood pressure measurement. The higher the blood pressure reading, the greater the risk. The new Northwestern Medicine study expands on that by showing a more accurate predictor is a change in blood pressure from age 41 to 55.

The study is published in Circulation: Journal of the American Heart Association.

We found the longer we can prevent hypertension or postpone it, the lower the risk for cardiovascular disease, said lead author Norrina Allen, assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine. Even for people with normal blood pressure, we want to make sure they keep it at that level, and it doesn't start increasing over time.

There hasn't been as much of a focus on keeping it low when people are in their 40's and 50's, Allen added. That's before a lot of people start focusing on cardiovascular disease risk factors. We've shown it's vital to start early.

People that maintain or reduce their blood pressure to normal levels by age 55 have the lowest lifetime risk for a heart attack or a stroke.

The study used data from 61,585 participants in the Cardiovascular Lifetime Risk Pooling Project. Starting with baseline blood pressure readings at age 41, researchers measured blood pressure again at age 55, then followed the patients until the occurrence of a first heart attack or stroke, death or age 95.

Men who developed high blood pressure in middle age or who started out with high blood pressure had a 70 percent risk of having a heart attack or stroke compared to a 41 percent risk for men who maintained low blood pressure or whose blood pressure decreased during the time period. Women who developed high blood pressure had almost a 50 percent risk of a heart attack or stroke compared to a 22 percent risk for those who kept their blood pressure low or saw a decrease.

Men generally have a 55 percent risk of cardiovascular disease in their lifetimes; women have a 40 percent risk.

Our research suggests people can take preventive steps to keep their blood pressure low early on to reduce their chances of a heart attack or stroke, said Donald M. Lloyd-Jones, MD, study co-author, chair of preventive medicine at Northwestern's Feinberg School and a cardiologist at Northwestern Memorial Hospital. Maintaining a healthy diet, combined with exercise and weight control, can help reduce blood pressure levels and, consequently, your risk for cardiovascular disease later in life.

ASE-EAE to issue guidelines for the echocardiographic evaluation of cancer patients

Thu, 20 Oct 2011 04:00:00 PST

( from http://www.rxpgnews.com ) Considering that the early detection of cardio toxicity is a critical issue for patients undergoing chemotherapy, the ASE and the EAE have come together to write guidelines which will highlight the technical advantages of echocardiography in identifying cardio toxicity early, explained Prof Juan Carlos Plana, Co-Director of the Cardio-oncology Center, Cleveland Clinic, from the ASE. This would help select patients who would benefit from cardio protective regimens, so that heart failure does not become an obstacle to the oncologist during therapy, and to the patient during his/her survival.

In the last decade cancer therapy has had an enormous progress leading to an important reduction of morbidity and mortality of several types of cancer. The therapeutic management of patients with cancer includes a combination of drugs, radiation therapy, and surgery. Several of these therapies, mainly anthracyclines, produce potential adverse cardiac reactions which can negatively impact the quality of life as well as the prognosis of oncologic patients. The new generation of targeted therapies (i.e. trastuzumab in breast cancer) has also been associated with unexpected unfavorable side effects on myocardial function. Currently, 17% of patients have to stop cancer therapy due to heart involvement.

Detecting cardio toxicity is a critical issue in the clinical setting, in order to appropriately modulate and, hopefully, not interrupt cancer therapy. The traditional screening of patients with cancer includes a cardiac examination, and both an electrocardiogram (EKG) and a 2D echocardiogram with Doppler at baseline. The monitoring of cardiovascular toxicity might be more accurate using endomyocardial biopsy. However, the test is highly invasive and not free from complications, stated Dr Maurizio Galderisi, from the Federico II University in Naples, Italy and chairperson of the EAE task force.

Echocardiography has emerged as the modality of choice for noninvasive evaluation of cardiac disease in the cancer patient. This tool is essential for the evaluation of left ventricular systolic and diastolic dysfunction, pericardial and valvular heart disease. However, echocardiograms are only routinely performed at the beginning of cancer therapy, in order to document a normal left ventricular systolic function. Further echocardiographic follow up during cancer therapy is performed only as a consequence of the onset of cardiac symptoms and/or signs, in particular following the administration of recognized cardiotoxic drugs or radiation therapy.

Dr Rosa Sicari, FESC, from the CNR Institute of Clinical Physiology, Pisa, Italy and chairperson of the EAE Scientific Committee adds that the assessment of cardiac toxicity remains a critical issue in oncology. Ejection fraction, the time honored parameter of function is not useful for the detection of early and subtle forms of cardiac dysfunction. New tools are needed and the evidence should be built in the near future with appropriately designed studies and with the common efforts of oncologists, cardiologists and pharmacologists. This document is not meant to fill the gap of knowledge but to provide the state of the art of ultrasound in this field and indicate new research pathways.

On these premises, the upcoming joint recommendations of the American Society of Echocardiography and European Association of Echocardiography will present the need and clinical usefulness of serial echocardiographic evaluations, and the potential impact of more advanced ultrasound technologies in patients undergoing cancer therapy.

Stroke rate 25 percent higher for Metis

Tue, 04 Oct 2011 04:00:00 PST

( from http://www.rxpgnews.com ) OTTAWA, Oct. 4, 2011 -- The stroke rate among Manitoba Metis is nearly 25 percent higher than for other Manitobans, according to a study by the University of Manitoba and the Manitoba Metis Federation (MMF) presented today at the Canadian Stroke Congress.

The higher stroke rate is driven by a 53 percent higher smoking rate, 34 percent higher rate of diabetes, and 13 percent higher rate of high blood pressure among Metis aged 40 years and older, compared to all other Manitobans. High blood pressure, smoking and diabetes are leading risk factors for stroke.

Being historically of both First Nation and European ancestries, but not really identifying as either one, Metis are a very unique people, but little research has been done on this population, says Dr. Judith Bartlett of the University of Manitoba and the MMF. It's really difficult for a health system to put in place Metis-specific programs if they don't understand what that means. Our job through this study is to link the health authorities with the Metis to bridge that knowledge gap.

The study linked the MMF membership list and several Canadian Community Health Survey cycles with Manitoba Health's hospital records throughout the province to create the Metis Population Data-Base, a one-of-a-kind registry of the 73,000 Metis in the province.

Despite universal health care, it is clear that stroke and related conditions are even more significant issues for Manitoba Metis than for all other residents in the province, the study says.

What are called knowledge networks of Metis and provincial Regional Health Authority (RHA) staff have now been established in each of the Manitoba Metis Federation's seven regions to look at the information from the study and interpret it within a local context, says Julianne Sanguins, Ph.D, of the Faculty of Medicine at the University of Manitoba and the MMF.

During the first few meetings of these knowledge networks, Metis Regions learned about available resources and the health-care providers discovered the strength of the Metis presence in their community, Dr. Sanguins says.

The ultimate purpose of these networks is to raise awareness about existing health services and then to make any necessary changes to the programs in each of the MMF/RHA regions to better meet the cultural needs of the Metis citizens.

It is important to learn more about the unique health challenges of Canada's Metis population in order to control risk factors and prevent stroke, says Dr. Antoine Hakim, CEO and Scientific Director of the Canadian Stroke Network. This study provides valuable information to create targeted education and outreach initiatives.''

Aboriginal people are twice as likely to die from stroke than the general Canadian population, says Heart and Stroke Foundation spokesperson Dr. Michael Hill. They are more likely to have high blood pressure and type 2 diabetes, putting First Nations, Inuit and Metis people at an even greater risk of stroke than the general population.

He says that culturally appropriate prevention strategies and novel health-care solutions will improve outcomes. Awareness of how to control risk factors such as high blood pressure, obesity, physical activity, diabetes, and smoking is essential.

Telestroke the next best thing

Tue, 04 Oct 2011 04:00:00 PST

( from http://www.rxpgnews.com ) OTTAWA, Oct. 4, 2011 -- The use of long-distance video and data hookups to link remote community hospitals with stroke neurologists in large centres provides the same level of care as having everyone in the same room, according to a new study presented today at the Canadian Stroke Congress.

The study found that rural patients examined with the aid of a technology called Telestroke received an important stroke drug, tPA, at the same rate as patients treated in specialized urban centres, says Dr. Thomas Jeerakathil, a neurologist at the University of Alberta Hospital. The drug tPA (tissue plasminogen activator) is used to break up blood clots. It can help reverse stroke damage if administered within 4.5 hours of the onset of symptoms.

Besides providing better care to remote communities, early projections show that Telestroke resulted in more than $1 million in health-care savings over four years, Dr. Jeerakathil says.

Telestroke is a way to bring the expert out to the rural centre to provide treatment that wouldn't otherwise be available, Dr. Jeerakathil says. And there is no delay in treatment despite the time required to set up video conferencing equipment and examine CT scans and blood work.

In the study, an initiative of the Alberta Provincial Stroke Strategy, University of Alberta Hospital neurologists observed the use of Telestroke in 10 primary stroke centres throughout remote parts of Northern Alberta over a four-year period.

During this time, tPA was administered to more than 500 people and, of those, 119 patients were treated with the help of Telestroke. Without access to the technology, these patients would have gone without treatment or been transferred to a bigger hospital and faced delays, says Dr. Jeerakathil.

Effective Telestroke treatment in remote areas contributed to a 50-per-cent decrease in emergency room transfers from rural areas to the University Hospital in Edmonton, says Dr. Jeerakathil. Some remote hospitals reported a decrease in transfers as high as 92 per cent.

Cost savings are occurring while outcomes are improving and stroke mortality is decreasing in the province, says Dr. Jeerakathil.

Telestroke allows small hospitals to be designated as primary stroke centres with many of the services of a major stroke unit. These primary stroke centres have a small sectioned off area with staff specially trained in stroke care, 24-hour access to a CT scan and the ability to give tPA.

Telestroke is severely under-utilized in Canada, says Dr. Antoine Hakim, CEO and Scientific Director of the Canadian Stroke Network. An audit of stroke care in Canada showed that fewer than 1 per cent of stroke patients received a Telestroke consultation. This study undeniably proves that Telestroke saves both lives and money.

Providing stroke patients fast and seamless access to stroke services regardless of where one lives in Canada will save lives and reduce disability, says Heart and Stroke Foundation spokesperson Dr. Michael Hill. Telestroke is another way that technology allows for an easy, cost-effective way to bridge geographic barriers to smoothly link stroke specialists with communities where on- site stroke care does not exist.

There are about 50,000 new strokes in Canada each year and 315,000 Canadians living with the after-effects of a stroke.

Undetected strokes increase risk

Tue, 04 Oct 2011 04:00:00 PST

( from http://www.rxpgnews.com ) OTTAWA, Oct. 4, 2011 -- Everyday, 1,000 people in Canada turn 65, entering a stage of life that has increasing risk of stroke and Alzheimer's disease.

Recent national and international imaging studies on the brains of people aged 65 and older show that 95 per cent have brain small vessel disease seen as white spots and patches on magnetic resonance images, says Dr. Sandra Black, director of the Brain Sciences Research Program at Sunnybrook Research Institute at the University of Toronto.

These studies also show that a quarter of healthy senior volunteers, average age 70, living in the community, have evidence of small silent strokes. Even in younger people (average age 60), this number may be as high as 14 per cent, according to preliminary results of the Canadian PURE MIND study, presented at the Canadian Stroke Congress in Ottawa, where Dr. Black addressed more than 900 researchers and clinicians.

Microbleeds, another type of small vessel disease, are associated with high blood pressure and with Alzheimer's disease, she says. Unlike major stroke events, these types of small vessel disease gradually build up and increase the risk of clinical stroke events, depression, falls and Alzheimer's dementia.

Alzheimer's and small vessel disease often live together in the brains of the elderly in a way that is very disabling, says Dr. Black. People become depressed, off balance when walking, have trouble thinking and often cannot live on their own. Unfortunately, so far there is no cure for either disease but there are actions we can all take to delay onset or progression.

The time is now for the brain to be the top priority for Canada's health research community, says Dr. Black. In the next 20 years the number of people with dementia and Alzheimer's disease is expected to reach more than one million in Canada alone, increasing ten-fold the current health care costs of$15 billion/year, she says.

Stroke is adding to the increasing incidence of dementia: 65 per cent of stroke patients experience difficulty with thinking, memory, goal setting and motivation after a stroke and 20 to 30 per cent become clinically demented within three months post-stroke, says Dr. Black.

Research for a cure is being actively pursued but, in the meantime, there are important counter measures people can take to delay and prevent these devastating diseases. This is because stroke and Alzheimer's share the same vascular risk factors, such as high blood pressure, obesity, diabetes, high cholesterol, smoking and a lifestyle of physical inactivity.

It turns out protecting the blood vessels in your heart and body also helps to protect your brain and its blood vessels. This can delay the onset of dementia, says Dr. Black.For example, regular aerobic exercise throughout the lifespan can help delay the onset of late life dementia, even more so in people who may be genetically prone to dementia.

Researchers from all fields are going to need to work together, says Dr. Antoine Hakim, CEO and Scientific Director of the Canadian Stroke Network

Lifestyle choices will have the biggest impact in protecting the hearts and brains of our aging population, says Heart and Stroke Foundation spokesperson Dr. Michael Hill.

Signs of aging may be linked to undetected blocked brain blood vessels

Thu, 01 Sep 2011 04:00:00 PST

( from http://www.rxpgnews.com ) Many common signs of aging, such as shaking hands, stooped posture and walking slower, may be due to tiny blocked vessels in the brain that can't be detected by current technology.

"This is very surprising," said Aron S. Buchman, M.D., lead author of the study and associate professor of neurological sciences at Rush University Medical Center in Chicago. "There is a very big public health consequence because we're not capturing this 30 percent who have undiagnosed small vessel disease that is not picked up by current technology. How would you even get them on your radar? We need additional tools in our toolkit."

In 1994, the researchers began conducting annual exams of 1,100 older nuns and priests for signs of aging. The participants also donated their brains for examination after death. This study provides results on the first 418 brain autopsies (61 percent women, average 88 years old at death).

Although Parkinson's disease occurs in only 5 percent of older people, at least half of people 85 and older have mild symptoms associated with the disease.

Before the study, researchers believed that something more common, such as microscopic blocked vessels, might be causing the physical decline. The study's autopsies found the small lesions could only be seen under a microscope after participants died.

The lesions couldn't be detected by current scans.

During the annual exams of the nuns and priests, researchers used the motor skills portion of a Parkinson's disease survey to assess their physical abilities.

"Often the mild motor symptoms are considered an expected part of aging," said Buchman, who is also a member of the Rush Alzheimer's Disease Center. "We shouldn't accept this as normal aging. We should try to fix it and understand it.

If there is an underlying cause, we can intervene and perhaps lessen the impact."

USF researchers get $2.6 million NIH grant to investigate new post-stroke therapy

Thu, 11 Aug 2011 04:00:00 PST

( from http://www.rxpgnews.com ) University of South Florida Department of Neurosurgery and Brain Repair faculty members have received a $2.6 million grant from the National Institutes of Health to investigate the potential for cells derived from human bone marrow to benefit post-stroke patients by repairing the blood-brain barrier (BBB). The BBB prevents harmful substances in circulating blood from entering the brain while allowing passage of needed substances.

According to the researchers, current treatment for ischemic stroke is limited to one FDA-approved drug, the serine protease tissue-type plasminogen activator (tPA) that to be effective must be administered during a three-hour window following a stroke.

Although there are almost 800,000 stroke cases yearly in the US, less than three percent of patients benefit from tPA treatment, said Dr. Svitlana Garbuzova-Davis, assistant professor in the Department of Neurosurgery and Brain Repair and co-principal investigator on the grant. Because of the drug's narrow three-hour therapeutic window, and its detrimental side effects that can exacerbate stroke injury and counteract the benefits provided by reperfusion of the occluded artery, new drugs are desperately needed.

According to Dr. Garbuzova-Davis, any treatment aimed at repairing stroke deficits should consider the pivotal role of BBB repair in order to maintain central nervous system (CNS) stability and enhance neuronal regeneration.

Permanent BBB damage can lead to harmful serum protein leakage into ischemic brain tissue and may result in the formation of severe brain swelling in the hours and days following a stroke, she explained. This damage could negatively influence CNS regenerative processes after a stroke.

Using animal models of stroke, the researchers will investigate how blood-brain barrier repair might mitigate the functional recovery in the stroke animals, and determine if BBB reconstitution can lead to positive therapeutic outcomes. Their research is aimed at discovering a potential mechanism underlying the BBB repair produced by stem cell transplantation.

We believe that a regenerative mechanism involving the repair of the damaged BBB by endothelial progenitor cells (EPCs) derived from bone marrow is critical to the successful outcome of cell therapy in stroke, explained Dr. Garbuzova-Davis. Whereas other cell-based technologies are largely designed to circumvent the BBB for delivery of cells or drugs from the periphery into the brain, we are taking a novel approach of repairing the BBB damage to lead to a therapeutic outcome for stroke victims.

According to the investigators, the site-specific EPC recruitment, followed by blood vessel repair processes, is important to exploiting BBB repair, a neglected therapeutic approach in stroke therapy. As these studies are designed to examine whether EPC transplantation extends the therapeutic window of tPA for stroke, the current research builds on the their long-standing goal of translating cell therapy from the laboratory to the clinic.

If BBB restoration via EPC transplantation alone or in combination with tPA is proven effective, the researchers believe that direct clinical application of this cell therapy could help a large population of ischemic stroke patients who may have missed the limited 3-hour tPA window, explained Dr. Paul R. Sanberg, director of USF's Center of Excellence for Aging and Brain Repair.

International organizations join forces to promote cardiovascular health

Wed, 06 Apr 2011 04:00:00 PST

( from http://www.rxpgnews.com ) This year's EuroPRevent meeting, 14 -16 April, is taking full advantage of its Geneva location and the close proximity to the European Headquarters of the World Health Organisation (WHO), the World Heart Federation (WHF), the United European Football Association (UEFA), and the International Olympics Committee (IOC).

On Thursday 14 April the European Association for Cardiovascular Prevention and Rehabilitation (EACPR) will host joint sessions including a session looking at the medical, legal and ethical aspects of eligibility screening for competitive sport with the IOC, a session looking at Cardiovascular prevention in Russia with WHO and WHF, a session looking at the Global challenges in CVD with the WHO and WHF, and a session looking at competitive sports in high risk patients with the IOC. It's a marvelous opportunity to be able to bring together all these organisations that are engaged in prevention and rehabilitation to fight heart disease and to provide science and practical tools to improve cardiovascular health both in Europe and also around the world, says Hugo Saner, the local organizer of the Congress.

EuroPRevent 2011, which represents the biggest meeting in Europe on cardiovascular prevention and rehabilitation, expects to attract over 1,500 delegates including epidemiologists, clinical cardiologists, sports physiologists, basic scientists, nutrition counsellors, physical therapists, nurses, sports teachers and psychologists. The field of cardiovascular prevention is currently gaining real momentum, says Volker Adams, chair person of the EuroPRevent Congress Programme Committee. For a while we've had the scientific knowledge, but now big strides are being made in improving the diagnostic technology and we're starting to see real political will power to bring about change. EuroPRevent 2011 brings all these aspects of prevention together.

The congress will be arranged around four main tracks: global challenges in prevention, new strategies and developments, sports cardiology and corporate health and prevention programmes.

This year, explains Adams, the sessions have been put together in a completely novel way with the intention of making them more inclusive and attractive to wider audiences. We've taken a topic and got different professionals to talk about them from different perspectives. The idea is that viewing topics from different angles will allow delegates to gain greater insights, says Volker Adams.

Sports cardiology is a major theme of the meeting with sports sessions running continually throughout the programme in room 2. Sport is really important for prevention because it helps promote healthy lifestyles across all age groups whether children or middle aged adults, says Hugo Saner.

Highlights of the meeting include two sessions on corporate health. Industry is beginning to appreciate that with an ageing population there's a real danger that they'll lose good employees to health problems and that this could lead to a lack of skilled workers. Companies are starting to appreciate that they need to take preventive measures to avert disaster, says Saner.

Distinguished speakers at EuroPRevent include Klaus Schwab, the founder of the World Economic Forum who is looking to promote a good attitude towards corporate health; Salim Yusuf from McMaster's University, Canada, who will be giving a personal view of what is needed in cardiac prevention; and Srinath Reddy, president of the Public Health Foundation of India, who will talk about the cardiovascular challenges facing India.

For the first time this year EuroPRevent will feature one late breaking session with six presentations of new research. In addition, 420 abstracts have been selected including 270 on prevention and epidemiology, 152 on rehabilitation and implementation, 45 on sports cardiology and 61 on exercise and translational science. Abstracts are really important because they give the young people starting out in the field a platform to showcase their work, says Adams.

University Hospitals system-approach to stroke care increases the use of tPA therapy by 13.5-fold

Fri, 11 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) University Hospitals (UH) Stroke and Cerebrovascular Center recently reported that it has increased the use of tPA or clot busting therapy for ischemic stroke by 13.5 times throughout UH system hospitals since implementing the System Stroke Program (SSP). Launched in 2008, SSP sought to increase access to the lifesaving treatment for acute (urgent) ischemic stroke patients in the 15 counties surrounding Cleveland.

tPA is Tissue Plasminogen Activator, a drug that dissolves blood clots and must be administered intravenously within 4.5 hours of the onset of stroke symptoms to be effective. tPA is the only drug approved by the U.S. Food and Drug Administration for the acute treatment of stroke and although tPA was approved for use in 1995, many hospitals did not have systems in place to evaluate or treat patients with this therapy.

Nationally, administration for stroke has increased in recent years through the development of Stroke Centers. However, the overall rate of use remains very low. According to a recently published study, the use of tPA increased nationally from less than 1 percent in 2001 to 2.4 percent in 2006.

When UH launched the SSP, the rate among UH hospitals was similar to the national rate, about 2 percent. Through the SSP efforts, that rate has increased dramatically to 27 percent.

According to Dr. Cathy Sila, director of the UH Stroke and Cerebrovascular Center, UH used its hub and spoke model, with UH Case Medical Center at the center offering stroke specialty teams around the clock, and the community hospitals acting as spokes off that hub. The stroke specialist doctors and nurses provided community hospital staff in the UH health system with education to accurately identify, assess, and treat patients who present with stroke symptoms and standard protocols to ensure that any patient coming to any UH hospital would receive the same high quality, evidence-based stroke care. Community hospital emergency medicine teams were trained to evaluate stroke patients for tPA eligibility, conduct urgent brain imaging scans and consult with the UH Case Medical Center stroke service to coordinate appropriate treatment plans.

As rapid tPA treatment is associated with better patient outcomes, patients need to receive treatment as soon as possible. Empowered by training and supported by the stroke specialists at UH Case Medical Center, our community hospitals have done a tremendous job in identifying eligible patients for tPA treatment and initiating that treatment without delay, said Dr. Sila. Patients are then transferred to UH Case Medical Center with trained critical care transport which is called 'drip and ship' therapy. The stroke team is waiting for them on arrival and if the patient has not responded to the tPA therapy, they are rapidly evaluated for other treatment options such as angiography.

The success of the SSP program was recently presented at the International Stroke Conference in Los Angeles.

Acute anemia linked to silent strokes in children

Fri, 11 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) Silent strokes, which have no immediate symptoms but could cause long-term cognitive and learning deficits, occur in a significant number of severely anemic children, especially those with sickle cell disease, according to research presented at the American Stroke Association's International Stroke Conference 2011.

One-quarter to one-third of children with sickle cell disease have evidence of silent strokes in their brains, according to Michael M. Dowling, M.D., Ph.D., lead author of the study and assistant professor of pediatrics and neurology at the University of Texas Southwestern Medical Center in Dallas.

These are 5- to 10-year-old children who have brains that look like the brains of 80-year-olds, Dowling said. These strokes are called 'silent' because they don't cause you to be weak on one side or have any obvious neurologic symptoms. But they can lead to poor academic performance and severe cognitive impairments.

Sickle cell disease is a blood disorder characterized by low levels of hemoglobin, the iron-containing component of red blood cells that carries oxygen. Low hemoglobin causes anemia. In sickle cell disease, the blood cells are misshapen (sickle-shaped) and may form clots or block blood vessels. About 10 percent of children with sickle cell disease suffer a stroke. Blood transfusions can reduce the high risk of repeat strokes.

Dowling and colleagues hypothesized that silent strokes occur during severe anemia and may be detectable by MRI. They used MRI on the brains of 52 hospitalized children 2- to 19-years-old at Children's Medical Center Dallas with hemoglobin concentrations dropping below 5.5 g/dL. They compared severely anemic children with sickle cell disease to a group of children without sickle cell disease who had hemoglobin levels below 5.5 g/dL.

They identified silent strokes in about 20 percent of the children with sickle cell disease who were experiencing acute anemia. They also saw evidence of silent strokes, though not as often, in severely anemic children who didn't have sickle cell disease.

The many reasons, besides sickle cell disease, why children could have anemia include trauma, surgery, iron deficiency or cancer such as leukemia.

These are brain injuries that go unnoticed by doctors, unless the children have testing with a special MRI, he said. We looked at every child who went to the hospital for a 30-month period and identified about 400 children that came in with hemoglobin below 5.5 g/dL. That represented about 12 percent of the admissions for sickle cell disease and about 1 percent of the total admissions to Children's Medical Center.

The findings suggest that children with or without sickle cell disease who have acute anemia could be suffering undetected brain damage. The researchers suggest that all children with severe anemia need careful examination for silent strokes.

Improved recognition and timely transfusion to increase blood hemoglobin levels could prevent permanent brain damage in children with silent strokes, according to the study.

Future studies should look at larger groups of children for longer periods to better understand the impact of acute anemia on children, Dowling said.

Final data show experimental agent better than aspirin at preventing stroke

Thu, 10 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) A new anti-clotting agent is vastly superior to aspirin at reducing stroke risk (1.6 percent per year versus 3.6 percent per year) in atrial fibrillation (AF) patients unable to take stronger drugs, according to final data reported today at the American Stroke Association's International Stroke Conference 2011. Researchers found the drug also works better in people with a history of stroke or a warning stroke.

Atrial fibrillation is a heartbeat abnormality that can cause blood clots which raise the risk of stroke, particularly in the elderly.

The AVERROES: Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Strokes trial is a randomized trial of 5,600 AF patients at moderate to high risk of stroke who were not willing or able to take oral vitamin-K antagonists like warfarin, a drug commonly prescribed to prevent blood clots in people with AF. They were treated at 520 medical centers worldwide. A May 2010 interim analysis found evidence that the investigational oral drug apixaban was so much more superior to aspirin that the researchers were advised to end the trial early, said Hans-Christoph Diener, M.D., professor and chairman, Department of Neurology and Stroke Center, University Hospital Essen, Essen, Germany.

In releasing the study's final results, he reported that apixaban was far superior to aspirin at preventing stroke or systemic embolism (blood clot) and was also very safe. The drug blocks factor Xa, a crucial step in blood clot formation, said Diener, co-chair of the study's adjudication committee.

Apixaban was highly superior to aspirin. We had not anticipated that apixaban would show such a big difference compared with aspirin while showing no significant increase in major bleeds, he said. Everyone had expected that a more powerful drug like apixaban would be associated with more severe bleeding complications compared to aspirin, but it wasn't.

The study's primary endpoint was the reduction of ischemic stroke (stroke caused by blockages in the brain's circulation), hemorrhagic stroke (stroke due to bleeding in the brain) and systemic embolism (blockages due to blood clots elsewhere in the body), he said. The primary safety endpoint was major bleeding incidents.

Up to 50 percent of all AF patients with moderate or high stroke risk are unsuitable for the most effective class of anti-clotting treatment known as vitamin K antagonists (VKA). That class includes the well-known drug warfarin.

All of the AVERROES patients were unsuitable for VKA therapy, which carries an increased risk of hemorrhage and requires frequent blood testing to monitor its effectiveness. For such patients the only alternate treatment is aspirin, which is just modestly effective, Diener said.

The patients in this study, all over age 50, were at moderate to high risk because they had at least one stroke risk factor in addition to AF, such as being age 75 or older, having high blood pressure, heart failure, diabetes or having a history of stroke or transient ischemic attack (a possible precursor of stroke), he explained.

Patients were randomized to receive either apixaban at 5 milligrams (mg) twice a day (2.5 mg twice a day in selected patients) or between 81 mg and 324 mg of aspirin per day. The study's double-dummy design mandated that patients randomized to receive apixaban took an aspirin-placebo and those randomized to receive aspirin got an apixaban-placebo, he explained.

During an average of 1.1 years of follow up, the researchers found 51 strokes or systemic embolism events in the 2,808 patients taking apixaban compared to 113 strokes and systemic embolic events in the 2,791 patients taking aspirin. That represents an annual rate of 1.6 percent for apixaban vs. 3.6 percent for aspirin, meaning apixaban carries about half the relative risk of stroke or systemic embolism compared to aspirin. Although bleeding events were slightly higher with apixaban, the difference fell short of statistical significance.

The researchers will also report on a subgroup of patients with a history of stroke or transient ischemic attack (TIA), often a precursor to stroke.

If validated by future studies I think this is the end of aspirin as a drug to prevent stroke in patients with AF, he added.

Diener said the study's major limitation is the limited time period of observation, shortened further by the study's early conclusion. AF patients need anticoagulation for the rest of their lives and we would have liked to see a much longer duration of the trial, he said.

By evaluating the use of apixaban as a replacement for aspirin in AF patients who are unsuitable for VKA therapy, the AVERROES study is addressing an important unmet clinical need.

Robot therapy can improve arm, shoulder mobility after stroke

Thu, 10 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) Therapy in which robots manipulate paralyzed arms, combined with standard rehabilitation, can improve arm and shoulder mobility in patients after stroke, according to research presented at the American Stroke Association's International Stroke Conference 2011.

Patients on robotic therapy showed marked improvement in two measures of upper extremity function: the Fugl-Meyer flexor synergy score, a 0 to 12 scale with higher numbers reflecting recovery of voluntary arm movement; and the Fugl-Meyer shoulder/elbow/forearm score, a 0 to 36 scale with higher numbers reflecting recovery of motor function in the shoulder, elbow and forearm.

Combining robotic exercise with regular rehabilitation may be the key to successful intervention, said Kayoko Takahashi, Sc.D., O.T.R., lead author of the study and clinician and research associate in the Department of Occupational Therapy in Kitasato University East Hospital in Kanagawa, Japan. Robots could allow therapists to focus on helping patients master daily activities while maintaining repetitive training, Takahashi said.

The new study involved 60 stroke survivors with hemiplegia (paralysis on one side of the body) treated at six rehabilitation centers in Japan. The patients, average age 65, had suffered a stroke in the previous four to eight weeks. All received standard rehabilitation therapy from an occupational therapist.

Half the group received robotic therapy every day for six weeks, in sessions lasting 40 minutes. The other half spent the same amount of time working through a standard self-training program for hemiplegic patients, performing stretches and passive-to-active exercises of their affected arm.

With a recent trend in helping patients function with one arm, many post-stroke patients have given up hope of recovery of their affected arms. Takahashi said. Participating in such robotic exercise is therefore expected to give patients insights about their future ability and a more positive image regarding their affected arm, increasing their self-efficacy and motivation toward rehabilitation.

The group assigned to robotic therapy used a Reo Therapy System by Motorika Ltd. in Israel. For the therapy, the patient's forearm, either resting on or strapped to a platform, is moved in multiple directions based on pre-programmed exercise movements.

Researchers selected five such pre-programmed movements. For instance, in one of the movements, forward reach, the robot helps patients extend their arms forward as if reaching for something in front of them.

Therapists also selected from five levels of robotic assistance according to what was most appropriate for the patient, from movement entirely guided by the robot and passive on the patient's part, to movement actively performed by the patient.

The successful test of robots adds a new wrinkle to stroke rehabilitation strategies, Takahashi said. While repetitive movement is an essential therapy, physical and occupational therapists aren't always available to provide care, and self-training, if not done correctly, can result in pain and disability.

Robots, on the other hand, can carry out the repetitive movement exercise with exactly the right movement pattern to prevent misuse, Takahashi said.

WSU study finds younger stroke victims benefit from earlier MRIs, ambulance rides to ER

Thu, 10 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) Detroit - While the American Stroke Association reports that stroke is the third leading cause of death and one of the top causes of disability in the United States, young adults showing signs of suffering a stroke are sometimes misdiagnosed in hospital emergency rooms, preventing them from receiving early effective treatment that can prevent serious damage.

Performing magnetic resonance imaging sooner on younger stroke patients entering emergency rooms can lower the rate of misdiagnosis and lead to faster appropriate treatment, according to a team of Wayne State University School of Medicine and Wayne State University Physician Group neurologists.

The Wayne State University-Detroit Medical Center Stroke Program team presented its findings Thursday during the American Heart Association/American Stroke Association's International Stroke Conference 2011 in Los Angeles, Calif.

In Early Performance of MRI is Associated with Lower Rate of Stroke Misdiagnosis in Young Adults, the team examined the cases of 77 patients with a mean age of 37.9 years who reported to an emergency room displaying stroke symptoms. Of those cases, 14.5 percent of the patients were initially misdiagnosed.

The chances of a misdiagnosis decreased if physicians performed an MRI of the patient within 48 hours. The likelihood of a misdiagnosis increased as the age of the patients decreased. The study concluded that early performance of an MRI leads to greater accuracy of a stroke diagnosis in young adults brought to emergency rooms, and patients younger than 35 years of age are at greater risk of being misdiagnosed when exhibiting stroke symptoms. However, if a patient demonstrating stroke symptoms arrived via ambulance, there was a lower rate of misdiagnosis. The team hypothesized that arrival by ambulance may increase an emergency room staff's perception of the gravity of the patient's condition.

Accurate diagnosis of stroke on initial presentation in young adults can reduce the number of patients who have continued paralysis and continued speech problems, said Seemant Chaturvedi, M.D., professor of Neurology and director of the WSU-DMC Stroke Program. We have seen several young patients who presented to emergency rooms with stroke-like symptoms within three to six hours of symptom onset, and these patients did not get proper treatment due to misdiagnosis. The first hours are really critical.

Part of the problem is that the emergency room staff may not be thinking 'stroke' when the patient is younger, Dr. Chaturvedi said. Physicians must realize that a stroke is the sudden onset of these symptoms. Patients arriving with seemingly trivial symptoms like vertigo and nausea should be assessed meticulously, he said.

Delay can be costly. After 48 to 72 hours, there are no major interventions available to improve stroke outcome, he said.

Intravenous delivery of the clot-dissolving agent tissue plasminogen activator is the only U.S. government-approved treatment for acute stroke. The drug must be administered within three hours of symptom onset to reduce permanent disability.

The findings build on the team's 2009 study in which members reviewed seven years worth of data covering 57 patients between the ages of 16 and 50. The patients were enrolled in the Young Stroke Registry at the Comprehensive Stroke Center at the WSU School of Medicine. Four males and three females (average age 34) in the study were misdiagnosed with migraine headaches, vertigo, alcohol intoxication or other conditions. They were discharged from the emergency room, but later were found to have suffered a stroke.

Advanced macular degeneration is associated with an increased risk

Wed, 09 Feb 2011 05:00:00 PST

( from http://www.rxpgnews.com ) Older people with late-stage, age-related macular degeneration (AMD) appear to be at increased risk of brain hemorrhage (bleeding stroke), but not stroke caused by brain infarction (blood clot), according to research presented at the American Stroke Association's International Stroke Conference 2011.

Other studies have found there are more strokes in older individuals with late AMD, but ours is the first to look at the specific types of strokes, said Renske G. Wieberdink, M.D., study researcher and epidemiologist at Erasmus Medical Center in Rotterdam, the Netherlands. We found the association is with brain hemorrhage, but not brain infarction.

AMD is degeneration of the macula, which is the part of the retina responsible for the sharp, central vision needed to read or drive. Because the macula primarily is affected in AMD, central vision loss may occur. Age-related macular degeneration usually produces a slow, painless loss of vision. Early signs of vision loss from AMD include shadowy areas in your central vision or unusually fuzzy or distorted vision.

Because the number of brain hemorrhages observed in the study was small, the findings will need to be corroborated in a larger group, Wieberdink said.

These findings should be considered preliminary, she said. Patients and physicians must be very careful not to over-interpret them. We don't know why there are more brain hemorrhages in these patients or what the relationship with AMD might be. This does not mean that all patients with late-stage AMD will develop brain hemorrhage.

Beginning in 1990, the Rotterdam Study is a prospective, population-based cohort investigation into factors that determine the occurrence of cardiovascular, neurological, ophthalmological, endocrinological and psychiatric diseases in older people.

The researchers tallied stroke incidence among 6,207 participants 55 years and older. All of the participants were stroke-free at the study's outset. AMD was assessed during scheduled eye examinations, and participants with the condition were divided into five different stages of AMD, and whether their condition was wet AMD or dry AMD. Participants were tracked for an average of 13 years. Of the 726 persons who suffered a stroke in that time, 397 were brain infarctions, 59 were brain hemorrhages and the stroke type was not available for 270.

Late AMD (stage 4) was associated with a 56 percent increased risk of any type of stroke. Late AMD, both the dry and the wet form, was strongly associated with more than six times the risk of brain hemorrhage, but not with brain infarction. Early AMD (stages 1-3) did not increase the risk of any stroke. Associations were adjusted for possible confounders, such as diabetes, blood pressure, anti-hypertensive medications, smoking status, body mass index, alcohol use and C-reactive protein levels.

Incidence of stroke after coronary artery bypass grafting surgery has decreased

Tue, 25 Jan 2011 19:14:17 PST

( from http://www.rxpgnews.com ) An analysis of data on more than 45,000 patients who underwent coronary artery bypass graft (CABG) surgery at an academic medical center over the past 30 years finds that the occurrence of stroke after CABG has declined, despite an increase in risk profiles of patients, according to a study in the January 26 issue of JAMA.

Stroke is a devastating and potentially preventable complication of CABG surgery. Because it increasingly is being reserved for elderly patients with extensive coronary disease and co-existing conditions, prevalence of stroke after CABG is likely to remain substantial. Many studies have identified patient factors associated with post-CABG stroke; however, information about timing of perioperative (around the time of surgery) stroke and the influence of different surgical techniques remains limited, according to background information in the article.

Khaldoun G. Tarakji, M.D., M.P.H., of the Cleveland Clinic, and colleagues examined the prevalence and timing of perioperative stroke, along with associated patient and surgical factors. The study included data from 45,432 patients (average age, 63 years) who underwent primary or reoperative CABG surgery from 1982 through 2009 at a U.S. academic medical center. Strokes occurring following CABG were recorded prospectively and classified as having occurred intraoperative or postoperatively. Data also included information on 4 different CABG operative strategies: off-pump (not on heart-lung machine), on-pump with beating heart, on-pump with arrested heart, on-pump with hypothermic circulatory arrest (in which a heart-lung machine is used to cool the body during surgery, which lowers blood pressure and slows circulation to near standstill).

Among the patients in the study, 705 (1.6 percent) experienced a stroke. Occurrence of stroke peaked in 1988 at 2.6 percent, then slowly declined by 4.69 percent per year, despite increasing patient risk profile, such as higher prevalence of preoperative stroke, hypertension, and diabetes. Of the 705 patients experiencing stroke, intraoperative stroke occurred in 40 percent (n = 279) and postoperative stroke in 58 percent (n = 409), with timing undetermined in 17 patients.

Risk factors common to both intraoperative and postoperative stroke included older age, previous stroke, preoperative atrial fibrillation, and on-pump CABG with hypothermic circulatory arrest. As number of arteriosclerotic (hardening and thickening of the walls of the arteries) co-existing conditions increased, stroke risk increased.

Different surgical techniques were associated with different risks of intraoperative stroke. Unadjusted rates of stroke were highest among patients who had on-pump CABG with hypothermic circulatory arrest (5.3 percent) and lowest among those who had off-pump CABG (0.14 percent) and on-pump beating-heart CABG (0 percent). Risk of intraoperative stroke was intermediate for those undergoing on-pump arrested-heart CABG (0.50 percent)

Patients who experienced a stroke had substantially worse hospital outcomes, even after adjustment for preoperative factors: 19 percent mortality vs. 3.7 percent; 44 percent prolonged ventilation vs. 15 percent; and 13 percent renal failure vs. 4.3 percent. They also experienced substantially longer intensive care unit and postoperative lengths of stay.

The authors speculate that the reason the occurrence of stroke among patients undergoing CABG has decreased over the last 3 decades despite an increasing patient risk profile may be the result of improving preoperative assessment, intraoperative anesthetic and surgical techniques, and postoperative care.

"Further studies are needed to develop better strategies to minimize the occurrence of stroke among patients undergoing CABG," the researchers conclude.

Statins: Benefits questionable in low-risk patients

Tue, 18 Jan 2011 05:00:00 PST

( from http://www.rxpgnews.com ) There is not enough evidence to recommend the widespread use of statins in people with no previous history of heart disease, according to a new Cochrane Systematic Review. Researchers say statins should be prescribed with caution in those at low risk of cardiovascular disease (CVD).

CVD is the most common cause of death, accounting for nearly a third of all deaths worldwide. Cholesterol-lowering statins are first line treatments for heart patients and the benefits are well established. However, there is less evidence that statins are beneficial for preventing heart problems in those who have no history of CVD. Given that low cholesterol has been shown to increase the risk of death from other causes, statins may do more harm than good in some patients.

The researchers reviewed data from 14 trials involving 34,272 patients. Outcomes in patients given statins were compared to outcomes in patients given placebos or usual care. Combined data from eight trials involving 28,161 patients that provided data on deaths from all causes showed that statins reduced the risk of dying from 9 to 8 deaths for every 1000 people treated with statins each year. Statins reduced fatal and non-fatal events, including heart attack, stroke and revascularization surgery, as well as blood cholesterol levels.

However, the researchers say that the conclusions of their review are limited by unclear, selective and potentially biased reporting and that careful consideration should be given to patients' individual risk profiles before prescribing statins.

It is not as simple as just extrapolating the effects from studies in people who have a history of heart disease, said lead researcher Fiona Taylor, from the Cochrane Heart Group at the London School of Hygiene and Tropical Medicine in London, UK. This review highlights important shortcomings in our knowledge about the effects of statins in people who have no previous history of CVD. The decision to prescribe statins in this group should not be taken lightly.

The researchers point out that all but one of the trials they reviewed were industry-sponsored. We know that industry-sponsored trials are more likely to report favourable results for drugs versus placebos, so we have to be cautious about interpreting these results, said Taylor. The numbers eligible for treatment with statins are potentially great so there might be motivations, for instance, to stop trials earlier if interim results support their use.

A separate Cochrane Systematic Review, conducted by some of the same authors, considered the effects of combined approaches to reducing the risk of heart disease, including using education and counselling to encourage people to change their diets and stop smoking. The authors concluded that combined interventions had little or no impact on deaths or disease caused by CVD. In an editorial accompanying the reviews, Carl Heneghan, University of Oxford, concluded that, Although various multiple prevention strategies exist, the most effective and cost-effective intervention for primary prevention in adults at low risk currently remains unclear.

Vitamin D deficit doubles risk of stroke in whites, but not in blacks

Sun, 14 Nov 2010 05:00:00 PST

( from http://www.rxpgnews.com ) Low levels of vitamin D, the essential nutrient obtained from milk, fortified cereals and exposure to sunlight, doubles the risk of stroke in whites, but not in blacks, according to a new report by researchers at Johns Hopkins.

Stroke is the nation's third leading cause of death, killing more than 140,000 Americans annually and temporarily or permanently disabling over half a million when there is a loss of blood flow to the brain.

Researchers say their findings, to be presented Nov. 15 at the American Heart Association's (AHA) annual Scientific Sessions in Chicago, back up evidence from earlier work at Johns Hopkins linking vitamin D deficiency to higher rates of death, heart disease and peripheral artery disease in adults.

The Hopkins team says its results fail to explain why African Americans, who are more likely to be vitamin D deficient due to their darker skin pigmentation's ability to block the sun's rays, also suffer from higher rates of stroke. Of the 176 study participants known to have died from stroke within a 14-year period, 116 were white and 60 were black. Still, African Americans had a 65 percent greater likelihood of suffering such a severe bleeding in or interruption of blood flow to the brain than whites, when age, other risk factors for stroke, and vitamin D deficiency were factored into their analysis.

Higher numbers for hypertension and diabetes definitely explain some of the excess risk for stroke in blacks compared to whites, but not this much risk, says study co-lead investigator and preventive cardiologist Erin Michos, M.D., M.H.S., an assistant professor at the Johns Hopkins University School of Medicine and its Heart and Vascular Institute. Something else is surely behind this problem. However, don't blame vitamin D deficits for the higher number of strokes in blacks.

Nearly 8,000 initially healthy men and women of both races were involved in the latest analysis, part of a larger, ongoing national health survey, in which the researchers compared the risk of death from stroke between those with the lowest blood levels of vitamin D to those with higher amounts. Among them, 6.6 percent of whites and 32.3 percent of blacks had severely low blood levels of vitamin D, which the experts say is less than 15 nanograms per milliliter.

It may be that blacks have adapted over the generations to vitamin D deficiency, so we are not going to see any compounding effects with stroke, says Michos, who notes that African Americans have adapted elsewhere to low levels of the bone-strengthening vitamin, with fewer incidents of bone fracture and greater overall bone density than seen in Caucasians.

In blacks, we may not need to raise vitamin D levels to the same level as in whites to minimize their risk of stroke says Michos, who emphasizes that clinical trials are needed to verify that supplements actually do prevent heart attacks and stroke. In her practice, she says, she monitors her patients' levels of the key nutrient as part of routine blood work while also testing for other known risk factors for heart disease and stroke, including blood pressure, glucose and lipid levels.

Michos cautions that the number of fatal strokes recorded in blacks may not have been statistically sufficient to find a relationship with vitamin D deficits. And she points out that the study only assessed information on deaths from stroke, not the more common brain incidents of stroke, which are usually non-fatal, or even mini-strokes, whose symptoms typically dissipate in a day or so. She says the team's next steps will be to evaluate cognitive brain function as well as non-fatal and transient strokes and any possible tie-ins to nutrient deficiency.

Besides helping to keep bones healthy, vitamin D plays an essential role in preventing abnormal cell growth, and in bolstering the body's immune system. The hormone-like nutrient also controls blood levels of calcium and phosphorus, essential chemicals in the body. Shortages of vitamin D have also been tied to increased rates of breast cancer and depression in the elderly.

Michos recommends that people maintain good vitamin D levels by eating diets rich in such fish as salmon and tuna, consuming vitamin-D fortified dairy products, and taking vitamin D supplements. She also promotes brief exposure daily to the sun's vitamin D-producing ultraviolet light. And to those concerned about the cancer risks linked to too much time spent in the sun, she says as little as 10 to 15 minutes of daily exposure is enough during the summer months.

If vitamin supplements are used, Michos says that daily doses between 1,000 and 2,000 international units are generally safe and beneficial for most people, but that people with the severe vitamin D deficits may need higher doses under close supervision by their physician to avoid possible risk of toxicity.

The U.S. Institute of Medicine (IOM) previously suggested that an adequate daily intake of vitamin D is between 200 and 600 international units. However, Michos argues that this may be woefully inadequate for most people to raise their vitamin D blood levels to a healthy 30 nanograms per milliliter. The IOM has set up an expert panel to review its vitamin D guidelines, with new recommendations expected by the end of the year. Previous results from the same nationwide survey showed that 41 percent of men and 53 percent of women have unhealthy amounts of vitamin D, with nutrient levels below 28 nanograms per milliliter.

Study gets measure of how best to prevent blood clots

Mon, 20 Sep 2010 04:00:00 PST

( from http://www.rxpgnews.com ) Treating hospital patients with thigh-length surgical stockings, rather than knee-high socks, can reduce life threatening blood clots, a new study suggests.

Researchers found that knee-high stockings, which are similar to flight socks, do little in stroke patients to prevent deep vein thrombosis (DVT), a life threatening form of blood clot that can travel up into the heart and lungs, .

The CLOTS (Clots in Legs Or sTockings after Stroke) study from the University of Edinburgh highlights that the clot rate in stroke patients was higher among those fitted with the shorter stockings than for those with longer stockings.

Another study, published last year by the same researchers, showed that thigh-length stockings did not usefully cut the risk of DVT in stroke patients.

This new study shows that short stockings are even less likely to help patients. The National Institute for Clinical Excellence have changed their guidelines based on these findings and no longer recommends that stockings are used for stroke patients.

However, stockings are also very widely used to prevent blood clots in patients who undergo surgery. Clinicians mostly use short stockings, which are cheaper and easier to fit than thigh-length stockings. In Scotland, for example, about three-quarters of stockings used by the NHS are short.

This study questions whether the widespread use of short stockings is appropriate given the greater risk of clots associated with their use. Use of short stockings may result in many more patients suffering potentially life-threatening clots.

The CLOTS trial included more than 3,000 stroke patients from 112 hospitals in nine countries.It is by far the biggest study to test stockings.

Stroke patients fitted with below-the-knee, stockings were 30 per cent more likely to develop deep vein thrombosis than patients fitted with thigh-length stockings. This could be because the most serious type of blood clots tend to be in the thigh, researchers suggest,

Martin Dennis, Professor of Stroke Medicine at the University of Edinburgh, said: Although we have shown in previous work that thigh-length stockings are not very effective in reducing the risk of DVT after a stroke, we believe that the results of this trial may have important implications for the millions of patients undergoing surgery each year.

Millions of patients worldwide are fitted with stockings each year. Unless reliable evidence emerges that short stockings do actually reduce the risk of DVT, long stockings should always be used in preference.

Although trials have shown that stockings reduce the risk of DVT in patients undergoing surgery, these have only tested long stockings. The researchers have not identified any studies which show that below-knee stockings work.

Success stops drug trial

Tue, 31 Aug 2010 04:00:00 PST

( from http://www.rxpgnews.com ) The data monitoring committee of the AVERROES study, seeing overwhelming evidence of the success of apixaban in the prevention of stroke in patients with atrial fibrillation who are unsuitable for the conventional treatment of warfarin, has recommended early termination of this study. The decision came after repeated review and careful consideration of all efficacy and safety data.

The study leaders, principal investigator Dr. Stuart J. Connolly, chairman of the steering committee Dr. Salim Yusuf, and project officer Dr. John Eikelboom, have accepted this recommendation, as have the study sponsors, Bristol-Myers Squibb and Pfizer.

Results of the study were presented by Connolly at the annual European Society of Cardiology Congress in Stockholm, Sweden, on August 31.

The AVERROES study enrolled 5,600 patients with atrial fibrillation at risk for stroke who were unsuitable for therapy with a Vitamin K antagonist such as warfarin. These patients were randomized, double-blind, to receive either apixaban or the standard therapy which is Aspirin. The primary efficacy outcome of the AVERROES study was a composite of stroke or systemic embolism and the major safety outcome was major bleeding.

The data monitoring committee observed a relative risk reduction for stroke and systemic embolism of more than 50 per cent, which was highly statistically significant and which met the highly conservative monitoring boundaries of the AVERROES study. There was only a modest increase in major hemorrhage that was not statistically significant.

The results of AVERROES are truly impressive, said Connolly, a professor of medicine at the Michael G. DeGroote School of Medicine at McMaster University. The reduction in stroke and systemic embolism is very important and the increased risk of hemorrhage is small. It appears that apixaban will be an excellent treatment for the many patients with atrial fibrillation who are unsuitable for warfarin. These findings will reduce the burden of stroke in society.

Atrial fibrillation is a common heart rhythm disorder, in which the upper chamber of the heart beats improperly. Patients with atrial fibrillation are at increased risk of stroke due to the formation of blood clots in the upper chamber of the heart. The standard therapy for the prevention of stroke and other embolic events in atrial fibrillation is to use a type of anticoagulant known as a Vitamin K antagonist. The most common Vitamin K antagonist is warfarin, which is very effective for reducing stroke but is a difficult drug to use because of numerous interactions with food and other drugs and due to a need for long-term monitoring each patient's blood coagulation.

There are many patients who are unsuitable for warfarin and for them the only effective therapy for prevention of stroke in atrial fibrillation is aspirin, which is not very effective. The purpose of the AVERROES study was to test whether the new Factor Xa inhibitor, apixaban, is superior to aspirin for the prevention of stroke in these patients, with an acceptable risk of bleeding.

Apixaban is a new type of anticoagulant known as a Factor Xa inhibitor, which is being jointly developed by Bristol-Myers Squibb and Pfizer. This agent blocks the coagulation system and can be used without the need for monitoring necessary in traditional treatments. It has been studied and shown promising results in patients with deep vein thrombosis, in patients with recent orthopedic surgery and after acute coronary syndrome. It had not previously been studied in patients with atrial fibrillation.

AVERROES investigators have been informed of the decision to stop follow up of patients in AVERROES, and soon they will be informing their patients who are participating in the study. All patients in AVERROES who are still receiving study medication will be offered a long-term, open-label extension phase of the study in which they will receive apixaban, once the extension has been approved by regulatory bodies and local ethics committees.

Health care using telephone and telemonitoring technology benefits heart failure patients

Sat, 07 Aug 2010 04:00:00 PST

( from http://www.rxpgnews.com ) Providing patients with chronic heart failure access to remote monitoring, for example by telephone or telemonitoring using wireless technology, reduces deaths and hospitalisations and may provide benefits on health care costs and quality of life. These are the conclusions of a new Cochrane Systematic Review by an international team of researchers.

Remote monitoring of patients can reduce pressure on resources, particularly for conditions like chronic heart failure, which exert a large burden on health services. In structured telephone support, patients provide vital data, such as heart rate and rhythm, blood pressure and weight, over the phone, whereas telemonitoring usually involves digital, wireless or Bluetooth transmission of data to a heart specialist.

The review included studies involving over 9,500 participants, comparing both of these technologies to usual care for patients with chronic heart failure. Studies that provided intensified specialist follow-up to patients in the intervention and/or control arms were excluded, since the additional resources provided may have confounded the effects of the intervention.

Details on deaths and hospitalisations for 25 peer-reviewed studies were analysed. The length of follow-up of these studies ranged from three to 18 months, with many studies reporting outcomes after 12 months. Telemonitoring was effective in reducing mortality in patients with chronic heart failure (102 per 1000 vs. 154 per 1000 in the control group). However, no significant benefit was seen with structured telephone support on mortality for patients in these trials (112 per 1000 vs. 127 per 1000 in the control group).

Both structured telephone support and telemonitoring significantly reduced the number of patients who were admitted to hospital due to worsening of heart failure. Hospitalisations due to heart failure occurred at a rate of 164 per 1000 with structured telephone support compared to 213 in a control group, and at a rate of 225 per 1000 with telemonitoring compared to 285 in a control group.

There are benefits of structured telephone support and telemonitoring for patients with chronic heart failure, said lead researcher Dr Sally Inglis of Baker IDI Heart and Diabetes Institute in Melbourne, Australia. These technologies can provide specialised care to a large number of patients who otherwise may have limited access to this type of specialised healthcare.

Some studies also showed patients' quality of life improved and that health care costs had been reduced. More work is required on the cost-effectiveness of telemonitoring to establish the best business models. These may vary depending on the local organisation of health services. The optimal duration of monitoring has not yet been addressed said Dr Inglis.

This review can only reflect the individual included studies. Of all the relevant evidence on these technologies which was included in the review, some studies were not as well conducted or reported as the authors would have liked - a point picked up in an Editorial published to accompany the review.

Image-processing algorithm reduces CT radiation dose by as much as 95 percent

Tue, 20 Jul 2010 04:00:00 PST

( from http://www.rxpgnews.com ) PHILADELPHIA, PA (July 20, 2010) -- Perfusion CT scanning, an emerging imaging technology, got a bad rap last year when a machine set to incorrect radiation levels overdosed hundreds of people in Los Angeles. In the wake of this incident, researchers at the Mayo Clinic, excited by the technology's promise for diagnosing stroke, cancer, and possibly heart disease, have developed a way to reduce the amount of radiation involved in the procedure -- which, when done properly, already involves very little risk.

At the correct dose, there should be no injury, said Cynthia McCollough. We believe in the clinical value of perfusion CT, so we're trying to lower the dose and reduce the stigma.

McCollough and her colleagues created a new image-processing algorithm that can give radiologists all of the information they need using as up to 20 times less radiation, depending on the diagnostic application. The research will be presented at the 52nd Annual Meeting of the American Association of Physicists in Medicine (AAPM) in Philadelphia.

A typical CT perfusion procedure lasts about half a minute and scans the same tissue many times, each scan at a low dose. These scans both reveal the internal anatomy of the patient and show how levels of a contrast agent, such as iodine injected into the bloodstream, change of over time. Changing concentrations of iodine can be used to calculate blood volume and flow in order to detect injuries to blood vessels or tumor responses to treatment.

The new adaptive algorithm compares these 20-30 scans and can differentiate between anatomical regions that do not change from moment to moment and those regions that carry the contrast agent --effectively reducing image noise while preserving iodine signal. The quality of each scan improves through non-linear comparisons with scans acquired earlier and later in the exam.

When we use very low doses, the noise gets so high that it's hard to tell what you are seeing, said Juan Carlos Ramirez Giraldo. With this algorithm, we're trying to maintain both the image quality, so that a doctor can recognize the anatomic structures, and the functional information, which is conveyed by analyzing the flow of the contrast agent over the many low dose scans.

At the AAPM meeting, the researchers will present animal data showing the effectiveness of the technique. They have also begun to process data from clinical brain perfusion CT exams in patients.

We're up to 15 or 20 cases that we've shown to the docs, and they're all giving us the thumbs up, said McCollough.

The presentation 20-Fold Dose Reduction Using a Gradient Adaptive Bilateral Filter: Demonstration Using in Vivo Animal Perfusion CT by J Ramirez Giraldo et al. will be at 7:30 a.m. on Tuesday, July 20 in room 201B of the Philadelphia Convention Center.

ABSTRACT:

Studies find treating vitamin D deficiency significantly reduces heart disease risk

Mon, 15 Mar 2010 04:00:00 PST

( from http://www.rxpgnews.com ) Preventing and treating heart disease in some patients could be as simple as supplementing their diet with extra vitamin D, according to two new studies at the Intermountain Medical Center Heart Institute in Murray, Utah.

Researchers at the Intermountain Medical Center Heart Institute last fall demonstrated the link between vitamin D deficiency and increased risk for coronary artery disease. These new studies show that treating vitamin D deficiency with supplements may help to prevent or reduce a person's risk for cardiovascular disease and a host of other chronic conditions. They also establish what level of vitamin D further enhances that risk reduction.

Study findings will be presented at the American College of Cardiology 59th annual scientific session in Atlanta at 3:30 pm, EST, on March 15, 2010. PLEASE NOTE EMBARGO REQUIREMENTS.

Vitamin D replacement therapy has long been associated with reducing the risk of fractures and diseases of the bone, says Dr. J. Brent Muhlestein, MD, director of cardiovascular research at the Intermountain Medical Center Heart Institute. But our findings show that vitamin D could have far greater implications in the treatment and reduction of cardiovascular disease and other chronic conditions than we previously thought.

For the first study, researchers followed two groups of patients for an average of one year each. In the first study group, over 9,400 patients, mostly female, reported low initial vitamin D levels, and had at least one follow up exam during that time period. Researchers found that 47 percent of the patients who increased their levels of vitamin D between the two visits showed a reduced risk for cardiovascular disease.

In the second study, researchers placed over 31,000 patients into three categories based on their levels of vitamin D. The patients in each category who increased their vitamin D levels to 43 nanograms per milliliter of blood or higher had lower rates of death, diabetes, cardiovascular disease, myocardial infarction, heart failure, high blood pressure, depression, and kidney failure. Currently, a level of 30 nanograms per milliliter is considered normal.

Heidi May, PhD, a cardiovascular clinical epidemiologist with the Intermountain Medical Center Heart Institute, and one of the study's authors, says the link between low levels of vitamin D and increased risk for a variety of diseases is significant.

It was very important to discover that the 'normal' levels are too low. Giving physicians a higher level to look for gives them one more tool in identifying patients at-risk and offering them better treatment, says Dr. May.

Dr. Muhlestein says the results of these studies will change the way he treats his patients.

Although randomized trials would be useful and are coming, I feel there is enough information here for me to start treatment based on these findings, he says.

Treatment options in this case are simple, starting with a blood test to determine a patient's vitamin D level. If low levels are detected, supplements and/or increased exposure to sunlight may be prescribed.

Increasing vitamin D intake by 1000 to 5000 international units (IU) a day may be appropriate, depending on a patient's health and genetic risk, says Dr. Muhlestein. He says supplements are the best source of vitamin D because they are relatively inexpensive and can be found at almost any supermarket or drug store. Most supplements provide an average of 400 IU per tablet.

While exposure to 20-30 minutes of sunlight can provide up to 10,000 IU, Dr. Muhlestein says it is important to use sunscreen and avoid the hottest parts of the day in order to avoid sunburn and the harmful UV rays associated with skin cancer.

New risk score tool more accurately predicts patients' risk for cardiac disease and death

Sun, 14 Mar 2010 04:59:36 PST

( from http://www.rxpgnews.com ) Researchers from the Heart Institute at Intermountain Medical Center in Murray, Utah, have devised a better way to determine an individual's risk for problems, such as heart attack and heart failure, according to a new study.

The research team has developed the Intermountain Risk Score, a measurement tool that looks at age and sex, but also adds the results of routine blood tests, which are not included in the assessment system commonly used by physicians today.

Researchers at Intermountain compared the Intermountain Risk Score with the Framingham Risk Score, currently the gold standard for measuring future coronary heart disease risk. The Framingham index looks at total cholesterol, HDL cholesterol, blood pressure, diabetes, age, and gender.

Framingham does a good job of classifying groups of patients. But it's not as good at indentifying an individual's risk for disease, says Benjamin Horne, PhD, director of cardiovascular and genetic epidemiology at the Heart Institute at Intermountain Medical Center, and the principal author of the study.

That's where the Intermountain Risk Score can help.

Our research has shown that the Intermountain Risk Score really improves a doctor's ability to measure patient risk. And it does it by including two simple and inexpensive tests: the complete blood count and metabolic profiles, he says.

Results of the study from the Heart Institute at Intermountain Medical Center will be presented at 1:30 pm, EST, on Sunday, March 14, at the American College of Cardiology's 59th annual scientific session in Atlanta.

Researchers followed over 5,000 patients who were treated for angiography, or vascular imaging. By combining the patients' Framingham Risk Score with their Intermountain Risk Score, researchers found that they were 30 percent more likely to correctly determine a woman's risk, and 57 percent more likely to determine a man's risk for a cardiovascular problem or death within 30 days of the angiography. The results remained substantially better than the Framingham score alone after one year (23 percent for women and 46 percent for men) and at five years (29 percent for women and 25 percent for men).

Adding the Intermountain Risk Score to the Framingham Risk Score substantially improves our ability to determine an individual's risk of future coronary heart disease and associated problems, says Dr. Horne.

The Framingham Risk Score was developed as part of the Framingham Heart Study, which began in 1948 as a project of the National Heart, Lung and Blood Institute and Boston University. The objective of the study was to identify common characteristics that contribute to cardiovascular disease by following its development over a long period of time in a large group of participants who had not yet developed symptoms or suffered a heart attack or stroke.

Researchers at Intermountain Medical Center followed patients an average of three years after their angiogram, and some were followed for up to 10 years.

We are in the process of replicating these findings at an academic center in North Carolina. Our previous studies of the Intermountain Risk Score showed that it applies very well both to patients and to the general population in different geographic settings, so we expect it will improve on the Framingham Risk Score in that East Coast population as well, Dr. Horne said. We are also evaluating which health conditions are best predicted by the Intermountain Risk Score, and how changes over time in laboratory values influence the scoring system's ability to predict health outcomes.

Dr. Horne says that the goal at Intermountain Healthcare is to create an online risk score calculator to help clinicians around the world better assess their patients' health.

Multicenter EPIC study found that the FiberNet Embolic Protection System had a 97.5% success rate

Mon, 01 Mar 2010 12:57:26 PST

( from http://www.rxpgnews.com ) A multicenter EPIC (FiberNet® Embolic Protection System in Carotid Artery Stenting Trial) study found that the FiberNet Embolic Protection System (EPS) had a 97.5% success rate when used in patients undergoing carotid artery stenting (CAS). Full findings are published early online in Catheterization and Cardiovascular Interventions, the official journal of The Society for Cardiovascular Angiography and Interventions.

Carotid artery stenosis or carotid artery disease occurs when plaque forms in the carotid artery, causing it to narrow and increasing risk for ischemic stroke. According to the National Institutes of Health, a blockage of a blood vessel is the most frequent cause of stroke, responsible for 80% of the estimated 700,000 strokes in the U.S. annually. Carotid artery stenosis is often treated with CAS, the placement of a tiny flexible tube in the diseased vessel.

Unfortunately, stenting procedures carry the risk of embolism, where plaque breaks away from the site of formation and blocks another artery downstream. Embolic protection devices have emerged to prevent strokes by catching the debris that may break away during CAS surgery. Over the past decade, several protection systems have emerged with varying degrees of success.

A research team led by Subbarao Myla, M.D, FSCAI, evaluated the safety and efficacy of this new design concept for embolic protection during CAS. The study was designed to demonstrate that the 30-day major adverse event (MAE) rate of all death, stroke, and myocardial infarction (MI) is significantly less than the performance goal of 8.3% from the ARCHeR 3 results.

The trial enrolled 237 patients with a mean age of 74 years from 26 centers across the U.S. and Europe. Study participants were 64% male and 20% had symptomatic carotid artery disease (CAD). Results indicate the combined MAE rate at 30 days following carotid endarterectomy (CEA) for all death, stroke and heart attack was 3.0%.

"The 30-day death, stroke, and MI rate of 3.0% is encouraging," says Dr. Myla. The researchers concluded that the FiberNet EPS, when used with commercially available stents, produced low stroke rates following CAS in high surgical risk patients with CAD.

Dr. Myla describes the team's experience with the new embolic protection device: "The low crossing profile and integration of a primary guidewire shortened procedure time, and facilitated lesion crossing and filter placement, especially in the presence of tortuous anatomy. The 0.014" guidewire tip demonstrated good torque response and the guidewire provided excellent support…it was ideal for procedures in which tortuosity would preclude placement of a more structured DPD with a stiff delivery catheter. Conformability of the expanded fiber network to the vessel wall and the short landing zone of the device made it ideal for challenging anatomy distal to the lesion. Anecdotally, investigators have commented the FiberNet EPS resulted in fewer vessel spasms."

Blacks more likely to have undiagnosed key stroke risk factor, have higher stroke incidence

Fri, 26 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) Blacks are more likely to have an undiagnosed key risk factor for stroke and are more likely to have a stroke than whites, according to two studies presented at the American Stroke Association's International Stroke Conference 2010.

In two separate reports using data from the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, researchers found significant racial and geographic disparities in stroke incidence and in receiving the recommended treatment to prevent stroke.

The REGARDS study enrolled 30,239 participants across the United States, age 45 or older, between January 2003 and October 2007 and continues to follow them for health events.

In the first analysis (Meschia, Abstract P160), researchers found that among 432 study participants (88 blacks; 344 whites) who had atrial fibrillation (AF), blacks were two-thirds less likely to know they had the disorder and three-fourths less likely to be treated with the gold standard of care, the blood thinner warfarin.

These disparities are a problem, said James F. Meschia, M.D., the study's lead author and a neurologist at the Mayo Clinic in Jacksonville, Fla. For patients who are able to take warfarin, it makes a huge difference. Stroke trials have shown that warfarin reduces the risk of stroke by 60 percent.

Meschia notes that warfarin is not for everyone, because of the risk of bleeding. AF, which affects more than 2.2 million Americans, occurs when one of the heart's upper chambers quivers and doesn't effectively pump blood out, which allows blood to pool and clot. These dangerous clots can cause stroke if they lodge in an artery in or leading to the brain. This research is also simultaneously published in Stroke: Journal of the American Heart Association.

Because atrial fibrillation is such a powerful risk factor for stroke, these findings suggest that lower awareness of atrial fibrillation and reduced likelihood of treatment among blacks may place blacks at higher risk of a stroke, which in turn could contribute to the higher stroke mortality among blacks, Meschia said.

The healthcare system needs to better screen for and inform people about whether they have AF, and more study is needed to shed light on the causes of the disparity in warfarin treatment, he said.

In the second analysis (Howard, abstract P158), researchers provide the first national data describing racial and regional disparities in stroke incidence. Researchers reviewed data on about 26,580 REGARDS participants who had not had a stroke at baseline and documented 299 strokes during the almost five-year period.

Total fat, trans fat linked to higher incidence of ischemic stroke

Wed, 24 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) Post-menopausal women who reported consuming the most daily dietary fat had a 40 percent higher incidence of clot-caused strokes compared to women who ate the least amount, according to research presented at the American Stroke Association's International Stroke Conference 2010.

The incidence of ischemic stroke also increased by 30 percent in the quartile of women consuming the highest daily amount of trans fat (average intake 7 grams per day) compared to those who consumed the least (average 1 gram/day). Two common sources of trans fat are processed foods and fried foods.

Ischemic strokes are caused by blockages in blood vessels in or leading to the brain.

We found positive associations between total fat intake and ischemic stroke incidence and between trans fat intake and ischemic stroke incidence, said Sirin Yaemsiri, M.S.P.H., a doctoral student in the department of epidemiology in the Gillings School of Global Public Health at the University of North Carolina in Chapel Hill.

The study is the first to examine the associations of different fats and different subtypes of ischemic stroke in post-menopausal women, who face a higher stroke risk than men of a similar age.

Evidence from other studies shows that different types of fat have different effects on the incidence of coronary heart disease (CHD), with trans fat implicated in the development of CHD. However, studies of ischemic stroke and fat have been inconclusive, possibly because earlier studies had small numbers of ischemic stroke cases.

Before menopause, women have a lower risk of stroke compared to men of similar age, a situation that reverses after menopause, Yaemsiri said.

The analysis included data on 87,230 post-menopausal women ages 50 to 79 who participated in the Women's Health Initiative (WHI) Observational Study, a project sponsored by the National Institutes of Health and the National Heart, Lung and Blood Institute. The women answered a food frequency questionnaire when they entered the study and were followed for an average of 7.6 years, the researchers said. During that time, 1,049 ischemic strokes occurred.

Researchers looked for links between dietary fat intake and four ischemic stroke subtypes, which were characterized by their size or point of origin. However, the data on ischemic stroke subtypes fell short of statistical significance, perhaps because strokes are difficult to characterize and 43 percent (445 cases) of the ischemic strokes in the study were of unknown type, Yaemsiri said.

Researchers divided the women into quartiles based on the amount of total dietary fat and types of fat (saturated fat, monounsaturated fat, polyunsaturated fat and trans fat) they reported consuming per day.

Variables included age, race, smoking status, physical activity, alcohol or aspirin use, body mass index, hormone therapy, heart disease history, diabetes, systolic blood pressure and whether the women took medication for high blood pressure or to reduce cholesterol, vitamin E supplementation, fruit/vegetable intake, total calories and dietary fiber.

Women in the top quartile for total fat intake had an average intake of 86 grams of total fat per day. Those in the lowest quartile consumed an average of 26 grams a day.

I think our findings support the American Heart Association recommendations for keeping trans fat intake at less than 1 percent of energy, said Ka He, M.D., Sc.D., M.P.H., senior author of the study and associate professor of nutrition and epidemiology at the UNC Gillings School of Global Public Health.

Vitamin B3 shows early promise in treatment of stroke

Wed, 24 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) An early study suggests that vitamin B3 or niacin, a common water-soluble vitamin, may help improve neurological function after stroke, according to Henry Ford Hospital researchers.

When rats with ischemic stroke were given niacin, their brains showed growth of new blood vessels, and sprouting of nerve cells which greatly improved neurological outcome.

Now research is underway at Henry Ford to investigate the effects of an extended-release form of niacin on stroke patients. Henry Ford is the only site nationally conducting such a study.

If this proves to also work well in our human trials, we'll then have the benefit of a low-cost, easily-tolerable treatment for one of the most neurologically devastating conditions, Michael Chopp, Ph.D., scientific director of the Henry Ford Neuroscience Institute.

Dr. Chopp will present results from the animal model study at the International Stroke Conference in San Antonio.

According to the National Stroke Association, stroke is the third-leading cause of death in America and a leading cause of disability.

Ischemic strokes occur as a result of an obstruction within a blood vessel supplying blood to the brain. Ischemic stroke accounts for about 87 percent of all cases. One underlying condition for this type of obstruction is the development of fatty cholesterol deposits lining the vessel walls.

Niacin is known to be the most effective medicine in current clinical use for increasing high-density lipoprotein cholesterol (HDL-C), which helps those fatty deposits.

Dr. Chopp and his colleagues found that in animals niacin helps restore neurological function in the brain following stroke.

In 2009, stroke physicians at Henry Ford Hospital published research which showed that HDL-C is abnormally low at the time stroke patients arrive at the hospital.

Dr. Chopp's research found that in animals, niacin increased good cholesterol (HDL-C), which increased blood vessels in the brain and axonal and dendritic growth leading to a substantial improvement in neurological function.

Niacin essentially re-wires the brain which has very exciting potential for use in humans, says Dr. Chopp. The results of this study may also open doors in other areas of neurological medicine, including brain injury.

Andrew Russman, D.O., is the principal investigator of the team at Henry Ford Hospital who will evaluate in clinical trials whether niacin improves recovery for human stroke patients.

If we are able to prove that treating patients with niacin helps to restore neurological function after stroke, we're opening a whole new avenue of treatment for the leading cause of serious long-term disability in adults, says Dr. Russman.

Changes during menopause increases risk of heart disease and stroke

Tue, 23 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) CHICAGO- When women hear the word menopause, they often think about hot flashes, hormone shifts and mood swings. But what about heart disease? Studies show a woman's risk of heart disease intensifies drastically around the time of natural menopause, which for most women is around the age of 50. This news may come as a surprise, but experts explain that understanding risk factors is an important first step, and reassure women that there are ways to lower your risk.

Many women younger than 50 have not yet gone through menopause and still have high levels of the female hormone estrogen in their blood, which is thought to help protect the heart. After menopause, however, the levels of estrogen in a woman's body drop significantly and can contribute to the higher risks of cardiovascular disease, explains Vera Rigolin,MD, associate director of the Center for Women's Cardiovascular Health in the Bluhm Cardiovascular Institute of Northwestern Memorial Hospital.

Weight gain is also a factor that may play a role in postmenopausal risk of heart disease. Maintaining a healthy weight often becomes difficult after your body experiences a change in hormone levels. Extra mass can take a toll on the body causing physical inactivity, high blood pressure, diabetes, and high cholesterol, all risk factors that can lead to heart attack and stroke.

Detecting heart disease in women can be difficult. Many women are unaware that symptoms of the disease may differ from those of men. Although women often experience chest discomfort when presenting with a heart attack, they commonly have other, more subtle symptoms, including fatigue, nausea, shortness of breath, jaw pain and general discomfort in the chest and abdominal area.

In some women, plaque can build in the smallest blood vessels called the microvascular circulation. These blockages do not show up in an angiogram, says Rigolin. In these cases, we often use Magnetic Resonance Imaging (MRI) with medication to visualize blood flow within the small blood vessels when other standard tests do not provide us answers.

Women, especially those who are menopausal can reduce the risk of heart disease by adopting a healthy lifestyle.

If you are a smoker, quit immediately and avoid second hand smoke. Eat a diet rich in fruits and vegetables and exercise at least three times per week to maintain a healthy body weight, says Rigolin.

Rigolin also recommends visiting your health care provider at least once per year to have your blood pressure, blood sugar and cholesterol levels checked.

High prevalence of AF found among cross-country skiers

Tue, 09 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) Next month, in the Norwegian town of Rena, 12,000 elite cross-country skiers will line up for this year's Birkebeiner ski marathon, an annual endurance race which will take them through 54 kilometres of snow-covered countryside to the winter sports resort of Lillehammer. The race has been run almost every year since 1932, and in 1976 almost 150 participants were invited to take part in a long-term study designed to discover the extent of latent heart disease in these elite cross-country skiers. Now, after some 30 years, the results of the follow-up study have been published and suggest that long-distance competition skiers - as well as other endurance athletes - are at an unusually high risk of atrial fibrillation, the most common abnormality of the heart's beating rhythm.(1)

Results showed that participants in the study are at a high risk of atrial fibrillation (AF) without known structural heart disease or other known causes (a condition termed lone AF). A prevalence of 12.8% found among the skiers who completed the study's investigations in 1976, 1981 and 2004-2006, when echocardiographic (ECG) and heart rate tests were performed at rest and at exercise. In the general population studies have found the prevalence of AF to be as low as 0.5%, with rates only rising to around 15% in men over the age of 75.

When the study began in 1976 participants were classified according to age - group I 26-33 years, group II 43-50 years, and group III 58-64 years; all had been competing in long-distance skiing events and were in the top 25% for age related performance. When the final follow-up examinations were performed during 2004-2006, a large proportion from group III (28/39) had died, leaving 78 of the original 122 available for further tests and questioning.

This analysis showed that 13 of those 78 skiers (16.7%) had experienced AF at some time during the 28-30 years of follow-up, with a current prevalence of 12.8% AF with no other known heart disease. The latter, say the investigators, is the highest prevalence yet described in long-term endurance sport practitioners. In age group I the prevalence was found to be 18.2%. The mean age at which the AF occurred was 58 years.

The study also detected two characteristics in the skiers which may predict their risk of AF: a slow heart rate at rest (known as bradycardia) and a large left atrium of the heart.(2) Both have been suggested in previous studies as common findings in the hearts of endurance athletes. However, the study found no association between the years of training in cross-country skiing (an average of 36 years in this study) and the occurrence of AF. As a result, the authors advise that there is still not enough evidence to recommend a specific age to reduce training volume and/or intensity. However, they do recommend that after the appearance of AF practice should be stopped or reduced until rhythm control is attained.

Disturbances in heart rhythm, which are the most common cause of sudden cardiac death, represent one of the major cardiovascular reasons for hospital admission. Professor Josep Brugada, President of the European Heart Rhythm Association of the ESC (and Medical Director at the Hospital Clinic in Barcelona), has described their impact as enormous, noting that around 5% of all medical expenditure in Europe is related to atrial fibrillation, the most common arrhythmic condition.

So far, only three case-control studies have found a higher prevalence of AF in athletes than in controls. However, a population-based study from 2009 showed that those with the highest level of endurance training also had the highest prevalence of AF.

Studies aiming to find an explanation for a higher AF prevalence have also found that the size of the heart muscle and chambers was larger in athletes than in controls, and this seemed a predictor for AF.

Commenting on the findings from the Birkebeiner study, principal investigator Dr Jostein Grimsmo from the Feiring Heart Clinic in Norway, agreed that enlargement of the heart's left atrium - along with bradycardia - appeared to be an important risk factor for AF among long-term endurance cross-country skiers. This atrial enlargement, he said, is the heart's adaptation to endurance training.

As many as 20% of young competitive athletes have been found to have an enlarged left atrium in some studies, said Dr Grimsmo. But we are not aware of any documentation of such a high prevalence as we have found either in athletes or in controls under the age of 75!

But despite our findings, he added, we still can't say why some athletes end up with AF and others don't. Genetic factors predisposing to 'athlete's heart', with enlarged cardiac dimensions and a slow heart rate, may be important as risk factors. And while it may be that prolonged endurance training over many years may not always be good for the heart, we do not yet have sufficient evidence to make specific recommendations.

NHLBI funds preclinical tests on devices for infants and children with congenital heart defects

Thu, 04 Feb 2010 05:00:00 PST

( from http://www.rxpgnews.com ) The National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health, has awarded four contracts totaling $23.6 million to begin preclinical testing of devices to help children born with congenital heart defects or those who develop heart failure. The four-year program is called Pumps for Kids, Infants, and Neonates (PumpKIN).

Each year in the United States, nearly 1,800 infants die as a result of congenital heart defects and another 350 develop heart disease, which leads to heart failure for many. Approximately 60 infants and children under 5 years old who are placed on the heart transplant waiting list die each year before receiving one. Mechanically assisted circulatory support could be used to sustain these young patients as they seek to recover or wait to receive a heart transplant.

This research seeks to develop technologies to expand life-saving options for infants and children born with congenital heart defects or those who develop heart failure, said NHLBI Acting Director Susan B. Shurin, M.D., a pediatrician. The NHLBI is committed to saving the lives of our youngest patients. Well-designed circulatory support devices are expected to substantially improve the outcomes of the infants and young children who need them as they seek to recover or wait to receive a heart transplant.

The options for chronic circulatory support devices for infants and young children are limited, and all have substantial risks for serious adverse events such as infection, stroke, and device failure. With this in mind, the NHLBI launched the Pediatric Circulatory Support Program in 2004 by funding the development of five novel circulatory support devices for infants and young children with congenital and acquired cardiovascular disease.

The PumpKIN program is the next phase of NHLBI support for the development and clinical realization of these devices. The program's goal is to complete the needed animal studies and other tests in artificial environments for the most promising devices in order to gain approval from the FDA to begin clinical testing.

Devices in the program will provide suitable circulatory support for newborns, older infants, and children less than 55 pounds who experience heart failure due to congenital and acquired cardiovascular disease. They are designed to supply adequate blood flow to prevent organ damage while minimizing the risk of blood vessel damage, infection, breakdown of red blood cells, excessive bleeding, brain damage, and dangerous blood clots. The devices are intended to support circulation in pediatric patients for one to six months, be sufficiently small and reasonably portable, and be able to be routinely positioned and functioning in less than one hour, among other specifications.

Similar devices are used in adults, Shurin noted. As an adult, your heart is normally about the size of your fist; devices for small children require radically different designs from adult devices to adapt to the differences in the size of the patients.

The program will test ventricular assist devices (VADs) and advanced extracorporeal membrane oxygenator (ECMO) devices. The VADs in the PumpKIN program are very small rotary pumps which are implanted to provide circulatory support for extended periods of use. They work by drawing blood from the heart and pumping it to the body. ECMO devices circulate and supply oxygen to the blood, and are commonly used for patients who need both heart and lung support. For ECMO devices, tubes connecting the patient to the device are placed directly into large blood vessels near the base of the neck. Blood is drawn from the right side of the heart, pumped through the oxygenator, and then returned to the body on the left side of the heart so the oxygen-rich blood can be delivered throughout the body.

The contractors will conduct all preclinical animal testing and analysis in the first three years of the contract. During the third year, they will partner with a data coordinating center (the contract for which is still to be awarded) to complete the necessary activities to seek FDA approval to begin the clinical trial.

Study prompts calls for Europe-wide salt legislation

Tue, 26 Jan 2010 05:00:00 PST

( from http://www.rxpgnews.com ) This study provides excellent ammunition both to convince patients about the benefits of reducing their individual salt intakes and also to persuade the EU of the urgent need to introduce legislation to restrict the salt content of processed foods, said ESC spokesman Professor Frank Ruschitzka, a cardiologist and hypertension specialist from the University of Zurich, Switzerland.

This study represents the evidence that a reduction of salt intake not only lowers blood pressure but also prevents cardiovascular events. The case for population-wide salt reduction is now compelling, he added.

In the paper, Kirsten Bibbins-Domingo and colleagues, from the University of California, San Francisco, USA, undertook a computer simulation showing the effects of population wide reductions of dietary salt intakes in all adults aged 35 to 85 years in the USA. Reducing dietary salt intake by 3 g per day (1200mg less sodium per day) could result in 60,000 to 120,000 fewer cases of heart disease , 32,000 to 66,000 fewer strokes and 54,000 to 100,000 fewer heart attacks.

A reduction in dietary salt of 3g per day, the authors went on to say, would have approximately the same effect on reducing cardiac events as a 50 % reduction in tobacco use, a 5% reduction in body mass index among obese adults or the use of statins to treat people at low or intermediate risk for CHD events. Furthermore, reducing dietary salt intakes by 3g per day would save $10 billion to $ 24 billion in annual health care costs.

ESC spokesperson Professor Giuseppe Mancia, from the University of Milano-Bicocca, St. Gerardo Hospital (Milan, Italy), said the annual health cost savings outlined in the study would be likely to prove a persuasive argument for both the EU and individual European governments.

Recent studies clearly show that salt reduction reduces cardiovascular deaths.4

Epidemiological studies have also firmly established that increased intakes of salt directly increase blood pressure. High salt intakes are believed to exert their detrimental effects by influencing fluid retention, which in turn increases blood pressure. But it's important for patients to appreciate that not all cardiovascular problems relating to salt are mediated through hypertension. Salt can have an adverse effect on cardiovascular health, even among people with normal blood pressure, said Ruschitzka.

Salt intakes across Europe are known to vary widely, ranging from 8.6 g of salt per day in the UK, to around 12 g salt in Croatia. Even the best intakes, however, are falling widely short of the ESC Clinical Practice Guidelines for the Management of Arterial Hypertension(2), based on WHO data, that recommend that only 5g of salt should be consumed per day. This amounts to just one teaspoonful.

While individuals may use salt sparingly at home, around 75 % of the salt we eat is already in the food we buy. This, says the ESC, underlines the need for legislation to lay down guidelines. The reality of international food production in Europe means that such public health initiatives need to be tackled on a European wide basis, rather than an individual country basis, said Ruschitzka.

Furthermore, added Mancia, concerted action is usually more effective. It has the advantage of preventing country to country inequalities and furthermore prevents the reinvention of the wheel in each individual country, he said.

But calls for legislation do not mean that physicians should stop their efforts to persuade patients to introduce individual changes in lifestyle. Patients, they stress, need to be taught about the importance of reducing salt in their cooking and also for the need to check food labels. People need to learn to appreciate that the salt contents can vary widely even in the same product. Take bread, for example. Recent research from Consensus Action on Salt and Health (a charity lobbying food manufacturers in the UK) has shown that the highest salt content was 3g salt per 100 g of bread, while the lowest was 0.7 g salt per 100g.

To improve cardiovascular health, salt reduction cannot be undertaken in isolation. It needs to be remembered that lifestyle measures such as smoking cessation, weight reduction, increased physical exercise, and eating plenty of fruit and vegetables are also important for reducing cardiovascular disease, said Mancia.

Salt will again be on the agenda with World Salt Awareness Week 2010 , which runs from February 1- 7 (3). The week is being run by World Action on Salt and Health (WASH), a global group that works with governments to highlight the need for widespread introduction of population based salt reduction strategies.

Much can be done to reduce salt intakes through public health policy, say WASH. They cite the success of Consensus Action on Salt and Health (CASH), launched in 1996 to encourage food manufacturing companies in the UK to make voluntary reductions in their salt content. Since the start of the policy salt intakes among UK adults (calculated from 24-hour urine samples) have fallen from 9.5 to 8.6 g per day.

In July 2009, WASH surveyed over 260 food products available around the world from food manufacturers such as KFC, McDonalds, Kellogg's, Nestle, Burger King and Subway, finding surprisingly wide spread variations. For example, Kellogg's All Bran for sale in France, Norway, Sweden and the Netherlands contains 1.30 g salt per 100 g compared to salt levels of 0.65 g per 100g for the product in the US. Such data underlines the urgent need to eradicate country to country inequalities, and bring everyone up to the highest possible standards.

The paper by Bibbins-Domingo and colleagues is an urgent call to action. Policy makers in the European Community need to implement public health interventions that result in reductions in salt intake now. Reducing the salt content of our unneccesarily oversalted ,processed food is an inexpensive, yet highly effective public health intervention that we can't afford to miss, concluded Ruschitzka.

Members of the European Parliament discuss achieving heart health in Europe

Wed, 09 Dec 2009 05:00:00 PST

( from http://www.rxpgnews.com ) Brussels, 9 December 2009 - Members of the European Parliament Heart Group (MEP HG) meet today, in Brussels, with the Cardiology profession and representatives of national Heart Foundations to evaluate the achievements at EU level in combating Cardiovascular Disease (CVD), and to reveal the need for further action.

With the title 'Achieving Heart Health in Europe: Why the European Parliament Matters', the meeting is the first since the European elections in June this year. During the 2004-2009 term, the MEP Heart Group was the largest forum on health in the European Parliament. The group resumes now its activities which endeavour to raise heart health as a priority on the EU political agenda. CVD is the number one killer in Europe, accounting for over 2 million deaths in the EU alone and costing the EU over 190 billion Euros each year. (1)

Mr Dirk Sterckx MEP, Co-chair of the MEP HG, believes that the European Union has a major role to play in fostering heart health promotion and developing wide-ranging prevention strategies. The European Parliament has set the example with the 2007 Resolution on action to tackle cardiovascular disease (2). However, the recent declining trends in CVD deaths in Europe are now slowing down. This is very worrying; it represents an alarm call to the European Commission and the Council.

The EU cannot turn its back on CVD, agrees Linda McAvan MEP, Co-chair of the MEP HG. Evidence does exist that prevention brings significant health gains. It is therefore the task of decision makers at European and national level to ensure that effective policies supporting prevention are put in place.

CVD is currently THE public health challenge in Europe, says Prof. Simon Capewell, Professor of Clinical Epidemiology, Liverpool University, UK. There are widening gaps both between and within Member States. CVD mortality rates have been decreasing in the past 30 years but they are now flattening. This is extremely frustrating because 80% of premature CVD deaths can be prevented by tackling the major risk factors, diet and smoking. A comprehensive European heart health strategy addressing health promotion and disease prevention is a moral responsibility for policymakers.

Significant policy developments addressing cardiovascular disease have taken place in Europe in the last decade. These include the Council Conclusions to promote heart health (adopted in 2004), the European Heart Health Charter (launched in 2007), and the European Parliament Resolution on action to tackle cardiovascular disease (adopted with a large majority in July 2007). Despite this, a tangible European strategy to address CVD is still non-existent. The MEP HG is calling for action from the European Commission and Member States to fill the gap. We urgently need to address what should be the Number 1 public health priority in Europe.

Migraine raises risk of most common form of stroke

Mon, 16 Nov 2009 05:00:00 PST

( from http://www.rxpgnews.com ) Pooling results from 21 studies, involving 622,381 men and women, researchers at Johns Hopkins have affirmed that migraine headaches are associated with more than twofold higher chances of the most common kind of stroke: those occurring when blood supply to the brain is suddenly cut off by the buildup of plaque or a blood clot.

The risk for those with migraines is 2.3 times those without, according to calculations from the Johns Hopkins team, to be presented Nov. 16 at the American Heart Association's (AHA) annual Scientific Sessions in Orlando. For those who experience aura, the sighting of flashing lights, zigzag lines and blurred side vision along with migraines, the risk of so-called ischemic stroke is 2.5 times higher, and in women, 2.9 times as high.

Study participants, mostly in North America and Europe, were between the ages 18 and 70, and none had suffered a stroke prior to enrollment.

Senior study investigator and cardiologist Saman Nazarian, M.D., says the team's latest analysis, believed to be the largest study of its kind on the topic, reinforces the relationship between migraine and stroke while correcting some discrepancies in previous analyses. For examples, a smaller combination study in 2005 by researchers in Montreal showed a bare doubling of risk, yet mixed together different mathematical measures of risk, while the Hopkins study kept them separate, pooling together only like measures. As well, another half dozen recent and smaller studies from Harvard University yielded mixed results, some showing a link between migraines and ischemic stroke, while one did not show a tie-in.

Nazarian says that while nearly 1,800 articles have been written about the relationship between migraine and ischemic stroke, the Hopkins review was more selective, combining only studies with similar designs and similar groups of people, and more comprehensive, including analysis of unpublished data.

Identifying people at highest risk is crucial to preventing disabling strokes, says Nazarian, an assistant professor at the Johns Hopkins University School of Medicine and its Heart and Vascular Institute. Based on this data, physicians should consider addressing stroke risk factors in patients with a history or signs of light flashes and blurry vision associated with severe headaches.

Prevention and treatment options for migraine, he says, range from smoking cessation and taking anti-blood pressure or blood-thinning medications, such as aspirin. In women with migraines, stopping use of oral contraceptives or hormone replacement therapy may be recommended.

Such widespread use of hormone-controlling drugs is what Nazarian says may explain why women with migraines have such high risk of ischemic stroke. Contraceptives and other estrogen therapies are both known to contribute to long-term risk factors for cardiovascular diseases and stroke, such as high blood pressure and increased reactivity by clot-forming blood platelets.

Nazarian says the researchers' next steps are to evaluate if preventive therapies, especially aspirin, offset the risk of ischemic stroke in people with migraines.

Women and cardiovascular health conference to highlight need for gender-specific research

Fri, 30 Oct 2009 04:00:00 PST

( from http://www.rxpgnews.com ) The 'Red Alert for Women's Hearts' conference, taking place on 5 November 2009, at the European Heart House, Sophia Antipolis, France, will address the subject of Women and CVD. The conference is jointly organised by the European Society of Cardiology (ESC) and European Heart Network (EHN), as part of Work Package 6 of the EuroHeart project (1).

Heart disease and stroke are the leading causes of death for women worldwide, killing more than 8.6 million, more than the total number who die from cancer, tuberculosis, HIV/AIDS and malaria combined.

However, the risk for women is largely under-estimated, by both the general population and often by the medical profession itself. This is due to the fact that women usually suffer from CVD 10 years later in their life than men: the risk increases after menopause, partly because of ovarian hormone deficiency that favours hypertension, diabetes, hyperlipidemia, central obesity and the metabolic syndrome.

In the report that will be presented at the conference (2), Professor Stramba Badiale, MD, PhD at the Department of Rehabilitation Medicine, IRCCS Istituto Auxologico Italiano, finds that women are underrepresented in cardiovascular research in Europe. In the 62 randomized clinical trials published between 2006 and July 2009, only 33.5% of enrolled participants were women, he says.

This underrepresentation is particularly noticeable in the fields of cholesterol-lowering therapy, ischaemic heart disease and heart failure.

Professor Roberto Ferrari, President of the ESC says: With regard to cardiovascular health, we do lack data for women simply because the majority of clinical trials are conducted on men. It is important to have special clinical trials conducted only on women because their cardiovascular pathology is, at least at some point during their lives, different from that of men and it is incorrect to apply data derived from studies on men to women.

Another finding of the report that supports the conference programme is that only 50% of the clinical trials conducted in the last three years which enrolled both men and women reported the analysis of the results by gender.

Susanne Logstrup, director of the EHN, regrets that, as a result, safety and efficacy of several drugs have been evaluated predominantly in male populations.

Professor Stramba-Badiale is hopeful that the report and the conference will encourage new practice amongst the research community, with a systematic enrolment of women in clinical trials. New data should improve the clinical management of CVD and, in the future, develop possible gender specific diagnostic and therapeutic strategies, he says.

The research is part of the EuroHeart project, which aims at defining areas of policies and public health interventions which can contribute to prevent avoidable deaths and disability across Europe. It is led by the ESC, in partnership with the EHN, and is co-funded by the European Commission Public Health Programme 2003-2008.

The 'Red alert for women's hearts' conference will systematically review the place of women in all aspects of scientific literature, whether clinical trials, guidelines, medical curriculum or regulatory processes.

More than 60 awareness campaigns addressing the particular issue of women and cardiovascular diseases have been organised in the last 20 years in the 19 countries participating in WP 6 of the EuroHeart project. This is evidence that national Heart Foundations and Cardiac Societies have long been aware of the urgent need to promote the issue amongst the female population and health professionals. The results of campaigns showed an increased awareness that cardiovascular diseases are the leading cause of death for women. Despite this, gender-specific training for cardiologists is still lacking in the majority of European countries.

The objective of this conference is to create a series of recommendations for policy makers, research funding agencies and regulatory entities, at both national and EU level.

Red Alert for Women's Hearts is also the opportunity to look at how countries address the lack of information of the population and of health professionals, by giving an overview of past campaigns and their impact, country by country.

NHLBI to convene symposium on cardiovascular regenerative medicine

Thu, 08 Oct 2009 04:00:00 PST

( from http://www.rxpgnews.com ) With advancements in the field of stem cell research accelerating, the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) will hold its third Symposium on Cardiovascular Regenerative Medicine to review the latest findings in the field and examine future directions. The symposium will include a discussion on ways to move promising findings in the laboratory into clinical trials, in hopes of speeding stem cell-related treatments to patients.

The event will be held Oct. 14 -15 at the Natcher Conference Center on the NIH campus in Bethesda, Md.

This symposium will help us move forward to spur new scientific efforts that will advance the field of cardiovascular stem cell research, said NHLBI Director Elizabeth G. Nabel, M.D., who will deliver the keynote address on the NHLBI Roadmap for stem cell research. With more than 16 million Americans living with damage to heart muscles or blood vessels due to heart attacks, this area of research holds great promise to improve lives.

Nabel noted that the theme of the symposium coincides with the NHLBI's recent funding of stem cell research projects under the American Recovery and Reinvestment Act. The NHLBI has made stem cell research a Signature Project under the Recovery Act and is putting a priority on funding research that could lead to the development of regenerative treatment for heart, lung, and blood diseases, added Nabel.

Some symposium sessions will focus on cardiac development and how epithelial cells transform into mesenchymal cells, a process which is related to organ development and some fibrotic diseases. Another session will review recent advances, and future potential, for embryonic stem cells and induced pluripotent stem (iPS) cells that could be used for cell therapy in the heart. IPS cells are artificially derived stem cells that can give rise to any fetal or adult cell type. The symposium will also feature a series of talks related to the NHLBI's newly launched Progenitor Cell Biology Consortium, whose 18 teams of scientists are developing the field of stem and progenitor cell tools and therapies.

Stem cell experts from the United States, Canada, the Netherlands, Spain, and Sweden are scheduled to speak, and the symposium will also include a number of poster sessions. Among the highlights of the scheduled list of speakers:

George Q. Daley, M.D., Ph.D., Harvard Medical School/Children's Hospital of Boston. Modeling Blood Disease with iPS Cells. Wednesday, Oct. 14, 8:35 a.m. Daley will discuss ways to use induced pluripotent stem cells to model blood disease. This line of research could provide new targets for drug therapy.

Bernhard Kuhn, M.D., Harvard Medical School/Children's Hospital of Boston, Stimulating Myocardial Regeneration with Cardiomyocyte Proliferation Factors. Thursday, Oct. 15, 11 a.m. Kuhn will discuss ways to recruit existing heart tissue into producing new cells, which could help repair heart damage following heart attack or stroke.

Jonas Frisen, M.D., Ph.D., Karolinska Institute, Sweden, Cardiomyocyte Renewal in Humans. Thursday, Oct. 15, 11:20 a.m. Frisen will discuss his work using residual atmospheric radiation remaining from aboveground atomic bomb testing in the 1960s from sites around the world to determine the age of cardiomyocytes, or cardiac muscle cells, in humans. Until now, it has been difficult to determine the age of cells in the heart, so there was little information about whether new tissue was being generated in the heart. Frisen's research suggests that a tiny fraction of tissue cells within the heart are new cardiomyocytes, a finding which could lead to new ways to encourage more such tissue growth.

New research to reduce drug side-effects

Fri, 10 Jul 2009 04:00:00 PST

( from http://www.rxpgnews.com ) They are a group of drugs which millions of people rely on to keep pain at bay but they can have unwanted side-effects which are sometimes more serious than the original health problem. Now scientists at The University of Nottingham are taking part in the largest-ever study on the safety of Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) that has ever been performed.

The project is called SOS (Safety Of non-Steroidal anti-inflammatory drugs) and will study the medical information of 35 million people in Europe to assess the incidence and nature of harmful side-effects on the cardiovascular and gastrointestinal systems of patients. It's hoped the results will lead to better guidance for doctors on how to balance the advantages of prescribing the drugs with the associated risks of heart and digestive problems.

NSAIDS are widely used in medicine for treating pain, inflammation and degenerative diseases like arthritis. The most commonly-used are aspirin and ibuprofen. But their use is associated with an increased risk of minor and serious gastrointestinal complications. It's estimated that there are thousands of these cases in the European Union every year. Prompted by these problems, a new class of NSAIDS called 'Coxibs' have been developed to reduce the risk of this type of side-effect, but the use of these new drugs has since been linked with an increased risk of heart problems such as heart attack and stroke.

Clinicians and scientists now agree that the risk of stomach problems has to be balanced against the risk of cardiovascular interference. Both risks may differ in one person and for the 30 different types of NSAIDS available in the EU. Up to now research studies have been too small to be effective in terms of providing decision models for doctors and drug regulators but it's hoped this new large survey will result in a much more accurate prescription method to minimize drug-related harm.

Over the next two and a half years, published literature on previous clinical trials and observational studies will be scrutinized to identify any methodological inconsistencies and knowledge gaps and this information will be used to design and carry out an EU-wide observational study. This study will be the biggest of its kind ever undertaken in this field. It will include data from more than 35 million Europeans, taken from existing healthcare databases in the UK, the Netherlands, Germany and Italy. The researchers will use the data to create a variety of decision models to help doctors prescribe the most suitable type of NSAID for a particular patient and lower the risk of unwanted gastrointestinal or cardiovascular side-effects.

The University of Nottingham is working with ten other leading European research institutions on the three-year project which is being funded with a 2.8 million Euros grant from the EC's 7th Framework Programme. Fundamental to the project is QResearch, a not-for-profit partnership between The University of Nottingham and leading primary care system supplier EMIS, which uses data collected over the past 17 years.

Professor of Clinical Epidemiology and General Practice, Julia Hippisley-Cox, who founded QResearch, said: The SOS project will help quantify and compare the risks of different NSAIDs based on an individual's profile and should help lead patients and doctors make better decisions regarding treatment options.

New research to reduce drug side-effects

Fri, 10 Jul 2009 04:00:00 PST

EUROPACE raises remote monitoring profile

Sun, 21 Jun 2009 04:00:00 PST

( from http://www.rxpgnews.com ) Moving to a more continuous follow-up approach would have the tremendous advantages of enhancing patient safety, decreasing physician and nurse work load, and allowing health staff to focus on medical emergencies, urged Professor Angelo Auricchio, from the European Heart Rhythm Association (EHRA) and official spokesperson of the European Society of Cardiology (ESC), adding that such systems may have the additional advantage of being more cost effective for health care providers.

Currently only around 1 % of patients in Europe with implantable cardiac devices are being monitored with remote devices, the majority are still being followed up by routine face to face clinic visits. Despite wide availability of remote monitoring in many European countries, few countries offer patients such systems. Even in countries that have introduced remote monitoring there are widespread disparities between centres, added Professor Auricchio, who works at the Cardiocentre Ticino (Lugano, Switzerland).

Cardiovascular implantable electronic devices (CIEDs) - which include cardiac pacemakers, implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy (CRT) devices, implantable cardiovascular monitors and implantable loop recorders - have now been developed with numerous programmable features allowing for storage of substantial amounts of diagnostic information.

The European Heart Rhythm Association (EHRA) and Heart Rhythm Society (HRS) expert consensus on monitoring of cardiovascular electronic devices, published last year, estimated that in 2006 approximately 250,000 pacemakers and 50,000 ICDs were implanted in Europe (1). The numbers implanted are estimated to be increasing by 5 to 10 % per year. What has become increasingly apparent, explained Professor Auricchio, is that once the device has been implanted, it needs to be followed up effectively to allow it to work efficiently.

This means that more than two million follow-up encounters with device patients are now needed in Europe each year, which is pushing the health care system to breaking point. Services are so overstretched by routine follow ups that they do not have much spare capacity to deal with emergencies when they come in, said Professor Auricchio.

The solution, suggests Professor Auricchio, is to increase the number of devices that can be interrogated remotely. Technology is available to download data related to device function, arrhythmia frequency, cardiovascular hemodynamic parameters and patient activity, from specific CIEDs and transmit the encrypted data using telephone technology to remote-secure monitoring centres. Here health care staff can both identify errant device behaviour, as well as patient's physiological response to a multitude of programmable therapies.

There are many advantages for remote devices. With the current face to face visit approach, physicians commonly first learn about critical device malfunctions and physiological changes when the patient returns to the clinic for a regular scheduled follow-up and manual device interrogation, which only takes place two to four times per year, depending on the patient status. With remote monitoring, problems can be identified immediately.

Continuous control of the device will permit detection of possible device dysfunction at a very early stage which allows us to take immediate action, thus improving patient safety significantly. said Professor Josep Brugada, President of the EHRA.

The European Heart Rhythm Association (EHRA) and Heart Rhythm Society (HRS) expert consensus document, which set out to determine what was needed to provide appropriate levels of care, concluded: Globalization and new Internet-based technologies for monitoring CIEDs are imposing new rules for patient data management and data-sharing. Competent authorities, national ministries of health, and patient organizations need to find practical and easy solutions for physicians to have rapid and complete access to device relevant data for delivering the most appropriate therapy.

The document adds that payers and regulators need to improve their recognition of the importance of CIED follow-up and develop adequate reimbursement strategies. There is no point investing in the device without comparable investment in the long-term follow-up and therapy! write the authors.

To understand the new models of reimbursement, EHRA in conjunction with Eucomed, now plans to survey the costs involved with in hospital CIED follow-up throughout Europe. In addition to the direct medical costs the survey will also include indirect costs, such as those involved in relatives accompanying patients on hospital visits. We need to have a better idea of the baseline costs so that we can start to understand the cost efficiency of introducing remote monitoring, said Professor Auricchio.

ESC Congress 2009: World's biggest cardiology meeting to be held in Barcelona

Wed, 03 Jun 2009 04:00:00 PST

( from http://www.rxpgnews.com ) The European Society of Cardiology Congress 2009, the world's biggest international meeting in Cardiology will be held in Barcelona, Spain, from 29 August to 2 September.

The meeting, which is expected to attract over 30,000 delegates, will provide opportunities for education, hearing about the latest ground breaking research and gaining deeper insights into the most recent developments and innovations in the diagnosis, treatment and prevention of Cardiovascular Disease. Delegates will include clinicians, basic scientists, epidemiologists, nurses, technicians and key opinion leaders in the field.

The latest results will be presented in the Hotline and Clinical trials sessions, with unique opportunities for delegates to have face to face interactions with the investigators. In addition, over 4,000 abstracts, featuring original research, will be show cased at the meeting.

The educational aspects of the congress include the Meet and Read with the Experts sessions and the highly acclaimed FOCUS Sessions with live transmissions and practical take home messages, not to mention reports on the latest ESC guidelines.

Prevention and risk factor identification is the special theme of this year's meeting, giving an opportunity for doctors, scientists, governments and the general public to come together to discuss ways of decreasing the burden of cardiovascular disease on society. Altogether there are 50 separate sessions on prevention in the pre arranged programme, and a special abstract session focusing on prevention research.

Additional highlights of this year's meeting include new joint sessions with sister societies, such as the European Society of Medical Oncology, looking at issues such as the cardiovascular effects of oncology drugs, a full day on Congenital Heart Disease and a new joint session with the European Commission exploring the issues around how the European Commission supports cardiovascular Research. A strong component is dedicated to basic science, including a hotline session looking at the latest development, a translational bench to bedside track and a special abstract session.

For the first time ESC 2009 will offer the opportunity for delegates to gain hands-on image and device education from clinical experts. The sessions, which are being held in purpose-built classrooms, have been organised by our industry partners, will be available free on a first come, first served basis. There will also be over 80 satellite symposia and workshops featuring the latest innovations in pharma and equipment.

All this is set against the truly inspirational city of Barcelona, with is magnificent Gaudi architecture, superb cuisine and world famous football team.

ESC 2009 promises to be a true festival of cardiology. There will be opportunities for hearing about the latest ground breaking trials, continuing education, not to forget the unrivalled opportunity for networking with colleagues from all disciplines of cardiology and finding out about practices in different countries, says Professor Fausto Pinto, Chairperson of the Congress Programme committee.

Better treatment selection and improved therapies -- key to improving prognosis in acute HF

Sat, 30 May 2009 04:00:00 PST

( from http://www.rxpgnews.com ) Today, acute heart failure represents the most common reason for hospitalisation in the over-65 population. Although hospital care improves symptoms in the first 24 hours after admission in around 50% of these patients, acute heart failure events still remain associated with a more than 50% mortality and rehospitalisation rate at 6-12 months. Indeed, says Professor Marco Metra from the Cardiology Department of the University of Brescia, Italy, it is the very rapid onset of symptoms and the need for urgent therapy which characterise the condition.1,2

Treatments in acute heart failure, he adds, have not undergone any great change in recent decades, despite the demand of heart failure's increasing prevalence and huge personal and public impact. Professor Metra said that treatments are still based on loop diuretics (furosemide), peripheral vasodilators (nitrates) and inotropic agents. Even the more recently approved treatments, he added, such as levosimendan in Europe and nesiritide in the USA, have been associated with uncertain effects on outcomes in randomised trials. So hospitalisations for acute heart failure are still associated with high mortality and rehospitalisation rates, he says. The burden is tremendous because of the large number of patients involved, their poor prognosis and the costs of the treatment.

In a presentation at Heart Failure Congress 2009 Professor Metra defined two major pathways along which this burden might be reduced and treatment improved:

* Better selection of treatments. To date, he said, therapy in acute heart failure has been administered with little attention to the clinical presentation of each patient. Guidelines on heart failure issued by the European Society of Cardiology in 2008 define heart failure as a heterogeneous condition and recommend that different therapies are used on the basis of clinical presentation; for example, patients with fluid overload should undergo fluid removal through diuretics or other means, patients with high blood pressure should receive mainly vasodilators, and patients with low cardiac output should be treated with inotropic agents to improve the force of the heart muscle's contraction.3

* Improved therapies. Many new agents are currently under development, said Professor Metra, which include adenosine type 1 receptors antagonists to enhance the diuretic effects of furosemide and increase renal blood flow, new vasodilators with different mechanisms of action, and new inotropic agents.

Better treatment selection and the development of new agents give us some hope that we will finally be able to improve the symptoms and prognosis of such a large patient population as that suffering from acute heart failure, says Professor Metra. However, he also emphasised that urgent therapy is one of the key recommendations of the latest European guidelines.

The cardiovascular benefits of daily exercise in school children are evident even after one year

Fri, 08 May 2009 04:00:00 PST

( from http://www.rxpgnews.com ) School children as young as 11 can benefit from a daily exercise programme in reducing their levels of several known risk factors for cardiovascular disease. An ongoing study, which began four years ago in the German city of Leipzig, shows already that children assigned to daily exercise lessons reduced their overall prevalence of obesity, improved their exercise capacity, increased their levels of HDL-cholesterol, and reduced their systolic blood pressure.

It's clear that children today have different lifestyles from the past, says investigator Dr Claudia Walther from the Heart Centre of the University of Leipzig. They're less active, and it was our hypothesis that an increase in their exercise activity would result in fewer risks of cardiovascular disease later in life.

The study, whose first-year results are reported at EuroPRevent 2009, randomised 188 school children with a mean age of 11.1 years (from seven classes at three different high schools) to either an active exercise programme in their school routine, or to a conventional curriculum of just two sports lessons a week. The exercise programme comprised daily supervised exercise which included at least 15 minutes of endurance training. So it was well controlled, says Dr Walther, with the teachers making sure that the programme was followed.

The first results presented here in Stockholm already show significant benefits for those in the daily exercise groups: in just one year the proportion of overweight and obese children decreased from 13% to 9%, but increased in the control group from 11% to 13%. These were statistically significant changes. Moreover, exercise capacity (as measured by VO2max) also improved significantly in the exercise groups by 29%. Similarly, levels of HDL-cholesterol and of triglycerides, and systolic blood pressure all improved in the exercise group.

Even from these first-year results we can say that regular physical activity has a significant beneficial effect on body composition, exercise capacity and cardiovascular risk markers in children, says Dr Walther, who adds that follow-up over the next 10-20 years will give some idea of how risk modification at this young age translates into benefit later in life.

The most surprising result, she says, was the effect of daily exercise on body weight, an effect not found so marked or so soon in other studies. These are normal children, explains Dr Walther, so we didn't expect such a significant reduction in the overall prevalence of obesity or excess weight.

Such findings have also raised local interest in Germany, where the investigators hope to extend the study to other neighbouring towns, and eventually to a daily exercise programme incorporated into the basic school curriculum.

It's so easy, says Dr Walther. All it needs is a little more time allocated to exercise lessons. The teachers are there, they supervise, and they all seem enthusiastic. If we can include daily exercise in the school curriculum, I'm sure we'll see an effect.

Poor sleep quality leads to poorer prognosis after stroke

Tue, 28 Apr 2009 04:00:00 PST

( from http://www.rxpgnews.com ) Stroke victims tend to do worse if they also have diagnosed or undiagnosed obstructive sleep apnea prior to having the stroke, according to a study presented April 28, 2009, at the American Academy of Neurology (AAN) annual meeting in Seattle.

Latha Stead, M.D., professor and chair of the Department of Emergency Medicine at the University of Rochester Medical Center, and professor of Neurosurgery, reported the findings at AAN, along with several other stroke studies measuring the factors that lead to a poor prognosis.

We know that obstructive sleep apnea has been linked to a multitude of cardiovascular problems, yet it is concerning that the vast majority of cases remain undiagnosed, Stead said. In the context of recovering from a stroke, sleep apnea can have a serious impact, and for that reason we encourage people to become more aware of obstructive sleep apnea and to get treatment.

The prospective study included 174 patients who were diagnosed with an acute ischemic stroke in the emergency department at the Mayo Clinic between June 2007 and March 2008. (Stead was the inaugural chair of the Division of Emergency Medicine Research at Mayo before recently joining the URMC.) The stroke-sleep study was conducted in collaboration with Virend Somers, M.D., Ph.D., who is well known for his work in sleep apnea.

Researchers used a standard questionnaire to assess the risk of sleep apnea among all 174 patients, sometimes aided by the patients' sleep partners. They found that 60 percent were at high risk of sleep apnea, seven patients had a previous diagnosis of sleep apnea, and those seven patients had a higher risk of death within the first month following the stroke.

After adjusting for age and stroke severity, researchers also found that high risk of obstructive sleep apnea was a predictor of having a worse outcome. Stroke patients with diagnosed or undiagnosed sleep apnea were also more disabled at the point of discharge from the hospital. Other studies have shown similar results, Stead said, but the latest research included a larger sample size compared to earlier studies.

Strokes are the third leading cause of death and the leading cause of disability in the United States. Since sleep apnea is a breathing disorder associated with the collapse of the pharyngeal airway, it causes potentially dangerous fluctuations in blood pressure.

Researchers do not know the exact mechanisms associated with sleep apnea and poorer outcomes following a stroke. But Stead noted it is more difficult for the brain and related tissue to heal when blood is not properly oxygenated during a disrupted sleep cycle. Furthermore, patients do not respond well to stroke rehabilitation programs when they are repeatedly sleep deprived.

The next step, she said, is to begin routine screening for obstructive sleep apnea as part of the emergency department evaluation of stroke patients.

Stead and research colleagues also presented a study at AAN showing that high blood sugar, or hyperglycemia, is another predictor of early death following a stroke. While other studies have shown that diabetics face poorer outcomes after a stroke, this study focused on non-diabetics or undiagnosed diabetics who had higher-than-normal blood sugar levels in the emergency department.

The important message is that in the Emergency Department setting, it's critical to investigate all of the known risk factors that indicate a poor prognosis following a stroke, Stead said. Other known risk factors include low blood pressure and irregular heart rhythm.

Stead's research is funded by a Mayo Foundation Emergency Medicine Research Career Development Award.

Telemonitoring changes the working practice of cardiac nurses

Wed, 08 Apr 2009 04:00:00 PST

( from http://www.rxpgnews.com ) The 9th Annual Spring Meeting of the European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions (CCNAP), organised in cooperation with the Irish Nurses Cardiovascular Association (INCA), is being held at the Royal Dublin Society, Dublin, Ireland, on 24-25 April.

The meeting - considered by many to be the premier international event for nurses and allied health professionals - will show case the latest advances in practice, education and research. The 400 plus delegates expected to attend from 26 different countries, will have the opportunity to hear wide ranging sessions covering all aspects of cardiology, including enhancing self care in heart failure populations, managing patients with ventricular assist devices, sudden cardiac death, hypertension, angina, and adult congenital heart disease, and improving primary and secondary prevention.

The theme of this year's meeting is Addressing the Challenges in Cardiovascular Care, with sessions exploring particular challenges of cardiovascular practice in the modern era, including diabetes and metabolic syndrome, behavioural change, and adherence to treatment. Sessions geared towards the practical management of cardiovascular care in daily situations will include how to incorporate guidelines into practice, take a cardiac history, improve assessment of heart sounds and interpret echo cardiograms. One innovative aspect of this year's meeting is the opportunity for health professionals to hear patients' personal perspectives on experiencing an implantable cardioverter defibrillator (ICD) storm, and having a ventricular assist device as a bridge to transplant.

The Spring Meeting is about improving cardiovascular care, and addressing the challenges we face, such as the rapid development of knowledge and technology, and the changing roles of nurses and allied health professionals, says Professor Christi Deaton, Chair person of the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP).

Mary O'Connor, President of the Irish Nurses Cardiovascular Association, who is co-hosting this year's meeting, adds: The meeting offers an invaluable opportunity for health professionals to network and meet with international colleagues to find out about the different ways of doing things. It allows best practice to be shared and will hopefully give delegates a lot of new ideas that they can introduce into their own clinical practice.

At the meeting more than 100 abstracts will be presented in poster, moderated poster and oral sessions reporting original research and clinical projects by nurses and allied health professionals. One such abstract by Ivonne Lesman (Groningen, The Netherlands) demonstrates that heart failure patients with new onset depression are significantly more likely to be readmitted to hospital (abstract 90082). The study, says Lesman, demonstrates the importance of screening for depressive symptoms in heart failure patients.

We hope that the presentation of high-quality research will encourage more nurses and allied professionals not only to read and review research, but also to conduct more well-designed studies that build evidence for practice, says Professor Deaton.

Mayo study shows simple finger device may help predict future heart events, such as heart attack

Thu, 26 Mar 2009 04:00:00 PST

( from http://www.rxpgnews.com ) ORLANDO, Fla. - Results of a Mayo Clinic study show that a simple, noninvasive finger sensor test is highly predictive of a major cardiac event, such as a heart attack or stroke, for people who are considered at low or moderate risk, according to researchers.

The study will be presented Tuesday, March 31, 2009 at 11:30 a.m. EDT at the American College of Cardiology Annual Scientific Session in Orlando (0917-7).

The noninvasive finger test device, called the EndoPAT by Itamar Medical, measures the health of endothelial cells by measuring blood flow. Endothelial cells line the blood vessels and regulate normal blood flow. Research has shown that if the cells don't function properly - a condition called endothelial dysfunction - it can set the stage for atherosclerosis (hardening of the arteries) and lead to major cardiovascular health problems. Previously, there was no simple test for endothelium function, says Amir Lerman, M.D., a cardiologist at Mayo Clinic and the senior author of the study.

Forty-nine percent of patients whose EndoPAT test indicated poor endothelial function had a cardiac event during the seven-year study. Researchers at Mayo Clinic and Tufts-New England Medical Center in Boston used the device to test 270 patients between the ages of 42 and 66 and followed their progress from August 1999 to August 2007. These patients already knew that they had low-to-medium risk of experiencing a major heart event, based on their Framingham Risk Score. The score is the commonly used risk predictor and was developed from the Framingham Heart Study, a longitudinal study of heart disease.

Some of their risk factors included high blood pressure, high cholesterol, obesity and a family history of heart disease, Dr. Lerman says. The results of the study may help identify a discriminating tool beyond the Framingham Risk Score, he says. And the results of these individual tests may help physicians change a patient's medications or recommend other therapies, so they don't have a heart attack or stroke later on.

The test may be used in an individualized medicine model of risk assessment of the patients, Dr. Lerman says.

EndoPAT, which received U.S. Food and Drug Administration approval in 2003, consists of digital recording equipment and two finger probes that look like large thimbles. For the test, which takes 15 minutes, probes are placed on each index finger and hooked up to a small machine to measure blood flow. A standard blood pressure cuff is placed on one arm; the arm without the cuff is the control. A reading of the fingers' blood flow rate begins, and then the blood pressure cuff on one arm is inflated for a few minutes and then deflated, allowing for three timed readings.

The role of the inflated blood pressure cuff is to occlude and then release blood flow to assess reactive hyperemia (RH), the normal blood flow response that occurs when occlusion is released. In the study, 49 percent of the patients who went on to have a cardiac event had a low RH score.

A low RH signal - indicating a lower blood flow response - is consistent with endothelial dysfunction and potentially impaired vascular health that may lead to or serve as a marker for future events, Dr. Lerman says.

Brain surgery on Monday, home on Tuesday

Wed, 25 Mar 2009 04:00:00 PST

( from http://www.rxpgnews.com ) MAYWOOD, Ill. -- Norma Wooley checked into Loyola University Hospital on a recent Monday morning for brain surgery to repair a life-threatening aneurysm.

She went home on Tuesday, cured of the slurred speech, drooping face and worst headache of her life.

Dr. John Whapham used a less-invasive technique that's becoming increasingly common in brain surgery. The Loyola University Health System neurologist inserted a catheter (thin tube) in an artery in Wooley's leg and guided it up to her brain. The catheter released tiny platinum coils into the bulging aneurysm, effectively sealing it off.

She went home the next morning with a Band Aid on her leg, Whapham said.

Whapham, 36, is part of a new generation of neurologists who are using catheters to repair aneurysms, open clogged arteries, extract blood clots and repair blood vessel malformations in the brain. He also opens blocked carotid arteries in the neck. The catheter technique is much less invasive and risky than traditional brain surgery, which involves cutting a large opening in the skull.

Catheter technology, originally developed for heart surgery, has been modified for narrower and more challenging blood vessels in the brain. There has been a huge evolution in devices over the last five years, Whapham said. Whapham is an assistant professor in the Departments of Neurology and Neurological Surgery, Loyola University Chicago Stritch School of Medicine.

Whapham recently joined Loyola University Health System. He is board certified in neurology and has completed fellowships in endovascular neurosurgery, diagnostic cerebral angiography and stroke/neuro-critical care.

Wooley, 54, of St. Charles, Ill., is one of Whapham's first patients at Loyola. Her successful treatment illustrates the benefits of performing brain surgery with catheters rather than scalpels.

Wooley had a cerebral aneurysm, a weak spot in a blood vessel that balloons out and fills with blood. About six million Americans -- 1 in 50 people -- have brain aneurysms that could rupture. Each year, aneurysms burst in about 25,000 people, and most die or suffer permanent disabilities, according to the Brain Aneurysm Foundation.

Wooley's aneurysm was roughly one-fourth inch across, and shaped like a gumball. It could burst at any time and cause a debilitating or fatal stroke. Her clinical presentation was suspicious for what's called a sentinel hemorrhage, in which an aneurysm on the brink of rupture will often perforate without catastrophic clinical or radiographic findings. One day at work, Wooley began slurring her words, as if she had been drinking. Her mouth and eyelid drooped, and she had a headache that felt like someone was hitting her on the back of her head with a baseball bat. An ambulance took her to a local hospital, and she was transferred to Loyola.

My brain was ready to explode, she said.

Traditional open-brain surgery to repair aneurysms is highly invasive, and recovery can take months. Many patients wind up with cognitive deficits that can, for example, make it impossible to do complex jobs.

Between 80 percent and 90 percent of brain aneurysms can be repaired with less-invasive catheters. Tiny coils of platinum wire are passed through the catheter and released into the bulging aneurysm. The aneurysm fills up with coils, causing the blood to clot. It's like filling a bathtub with concrete, Whapham said.

A landmark clinical trial known as ISAT randomly assigned aneurysm patients to receive either open brain surgery or catheter surgery. The catheter group had significantly lower rates of death and disability. Whapham said catheter surgery techniques and devices have improved dramatically since the study was published in 2002 in the British journal

Stroke survivors improve balance with tai chi

Mon, 23 Mar 2009 04:00:00 PST

( from http://www.rxpgnews.com ) Stroke can impair balance, heightening the risk of a debilitating fall. But a University of Illinois at Chicago researcher has found that stroke survivors can improve their balance by practicing the Chinese martial art of tai chi.

Christina Hui-Chan, professor and head of physical therapy at UIC, has studied and used tai chi as a way to improve balance and minimize falls among healthy elderly subjects. Now she and a colleague have seen similar results in a group of stroke survivors.

The study used 136 subjects in Hong Kong who had suffered a stroke more than six months earlier. Participants were randomly assigned to a tai chi group or a control group that practiced breathing, stretching and other exercises that involved sitting, walking, memorizing and reasoning.

Tai chi consists of constant coordinated movement of the head, trunk and limbs requiring tremendous concentration and balance control. Participants learned a simplified form that had been shown to be beneficial to arthritis patients.

Patients were trained in small groups by physical therapists in a weekly class, then practiced at home three days a week for one hour. They received 12 weeks of training but were able to learn the technique in as little as eight. The goal was to make the patients as independent in their treatment as possible, Hui-Chan said.

They were then tested for their ability to maintain balance while shifting weight, leaning in different directions, and standing on moving surfaces to simulate a crowded bus. In these tests the tai chi group out-performed the control exercise group. The two groups performed about the same on another test, which was not focused solely on balance but involved sitting, standing, walking, and returning to sit down.

The tai chi group did particularly better in conditions that required them to use their balance control, Hui-Chan said. In only six weeks, we saw significant improvements. The ability to shift your weight is very important because all reaching tasks require it.

While learning tai chi is not easy, Hui-Chan has found that most people can learn the art if taught by a trained instructor. Many Chinese practice tai chi in morning group exercises, and Hui-Chan thinks the experience can work for Americans and other western nationalities.

It can be taught at community centers, YWCAs or YMCAs, or in parks in the summer, she said.

Hui-Chan said that benefits of tai chi include improved strength and cardio fitness. Group classes also provide a healthy social gathering for isolated seniors at a fraction the cost of physiotherapy or personal training.

Cardiac imaging highlighted at Biennial ICNC-9

Mon, 16 Mar 2009 04:00:00 PST

( from http://www.rxpgnews.com ) ICNC9, the key international scientific meeting on Nuclear Cardiology and Cardiac CT, is taking place in Barcelona, 10-13 May.

ICNC, a joint venture between the ESC Working Group on Nuclear Cardiology and Cardiac Computed Tomography, the European Association of Nuclear Medicine (EANM) and the American Society of Nuclear Cardiology (ASNC), now in its 18th year, aims to promote excellence in Nuclear Cardiology and Cardiac CT through practice, education and research. The biannual meeting - which gathers over one thousand cardiologists, nuclear medicine doctors, radiologists, imaging technologists, nurses, physicists, and industry representatives from over 40 countries - provides a unique opportunity for delegates to learn more about the state of the art of cardiac imaging, and its future directions.

Imaging represents a real growth area in cardiology, with more and more guidelines now stating the need for imaging. But it's still not currently the main stream, making it imperative that more cardiologists get up to speed in the area, says Professor Juhani Knuuti, Co-Chair of the meeting.

Cardiac imagining is the key for decision-making in cardiology, permitting resources, such as medications and coronary revascularization, i.e. cardiac surgery or angioplasty, to be used for maximum patient benefit, says Professor Robert Hendel meeting Co-Chair.

ICNC9 is a really important medical meeting because everything novel in the field of imaging will be highlighted here, says Professor Jeroen Bax, former chair and programme chair of ICNC. Such sub-speciality meetings, which are tightly focussed on specific areas of cardiology, offer a really valuable opportunity to advance frontiers in medicine. At ICNC9, all cardiac imaging modalities will be featured including nuclear cardiology techniques (such as SPECT and PET), cardiac computed tomography (CT), cardiac MR, and echocardiography. This year, a special focus will be present on cardiac CT, with sessions being held in every available time slot at the meeting.

Revolutionary advances in cardiac imaging and its applications will be featured during this meeting. Additionally, ICNC9 provides a great opportunity for health care professionals to meet and develop new strategies for imaging within clinical practice says Professor Hendel.

At the 2009 meeting, there will be a particular focus on integrating the different imaging technologies for the ultimate benefit of patients. When treating patients, clinicians shouldn't apply modality based thinking, but should be using the technology best suited to the clinical questions they want to answer, says Professor Knuuti.

An example of the way imaging technologies can be helpfully combined is using CT for information on the anatomy of coronary arteries and nuclear tests for information on haemodynamics. Combining these two modalities provides both the best diagnostic and prognostic information, with a much more complete picture for the patient, says Professor Bax.

A unique feature of ICNC is that the programme can be accessed at different levels of expertise. Essential sessions review fundamentals to help new comers to the field get up to speed, Core Curriculum sessions address the current big clinical questions, and Advance sessions consider the future directions. Technological advances to be covered will include:

Young black adults have higher rates of stroke than white counterparts

Mon, 16 Mar 2009 01:22:31 PST

( from http://www.rxpgnews.com ) In Florida, black young adults are hospitalized for stroke at a rate three times higher than their white and Hispanic peers, a new study by University of South Florida researchers reports. The study was presented today at the American Heart Association's Council on Epidemiology and Prevention Annual Conference and appears in the online version of the international journal Neuroepidemiology.

Disparities in stroke outcomes between black and white patients have been widely reported for years. While overall death rates for stroke are down, blacks bear a disproportionate burden of disease, disability and death from strokes, said lead author Elizabeth Barnett Pathak, PhD, associate professor of epidemiology at the USF College of Public Health.

"Our study shows this black-white disparity hasn't improved. In fact, it's clear that the gap emerges even at relatively young ages – among adults hospitalized for strokes in their 20s and 30s – and widens with increasing age," Dr. Pathak said. "It points toward an urgent need for primary prevention of hypertension, obesity, and other stroke risk factors among African Americans to eliminate disparities in stroke."

While most strokes occur among the elderly, stroke in young adults can lead to chronic illness and disability that places a terrible burden on the victims and their families, said Michael Sloan, MD, professor of neurology and director of the USF Stroke Program at Tampa General Hospital. "If the stroke is severe it can be very debilitating, impacting the ability of young people to work and raise their families."

And even in young adults strokes can be fatal. The Florida study found 8 to 10 percent of stroke patients died before discharge from the hospital.

The USF researchers examined more than 16,000 stroke cases of young adults hospitalized for stroke in Florida from 2001 through 2006. The study included men and women, ages 25 to 49, from the three largest ethnic groups in Florida: whites, blacks and Hispanics. Among the findings:

The age-adjusted stroke hospitalization rate for blacks was three times higher than for whites or Hispanics. Stroke hospitalization rates for Hispanics were similar to those for whites.

The rates at which hospitalized stroke patients died were 15 percent higher for blacks than whites, but this disparity was explained by a greater prevalence of stroke risk factors and complicating illnesses such as diabetes, coronary artery disease and heart failure.

In contrast, Hispanic stroke patients were 27 percent less likely to die in the hospital than whites after taking risk factors and other illnesses into account. More studies are needed to determine whether Hispanic ethnicity actually confers any sort of protective advantage, the researchers said.

Black stroke patients were more likely than whites and Hispanics to have been diagnosed with high blood pressure, morbid obesity or drug abuse. White stroke patients were more likely to have been diagnosed with high cholesterol, alcohol abuse or cigarette smoking.

The majority of black stroke patients (56 percent) where women, while the majority of Hispanic and white patients were men.

Hispanics were more likely than blacks and whites to suffer a hemorrhagic stroke, triggered by the rupture of a blood vessel in the brain. As with the elderly, the most common type of stroke in younger adults, known as ischemic stroke, was caused by the obstruction of blood flow to the brain.

While the USF study did not find an increase (or decrease) in young adults hospitalized for stroke in Florida, Dr. Sloan is concerned that tough economic times may lead to rise in strokes and other cardiovascular incidents. "When people stop taking their blood pressure pills and other medications because they can no longer afford it, they have strokes and heart attacks," he said.

Preventing a second stroke is focus of study at Rush University Medical Center

Tue, 03 Mar 2009 05:00:00 PST

( from http://www.rxpgnews.com ) Rush University Medical Center is participating in a National Institutes of Health (NIH) study to determine the best course of treatment to reduce the risk of stroke patients suffering another stroke. The study will determine if aggressive treatment of stroke victims for high blood pressure and cholesterol, along with placing a stent to widen a narrowed artery in a patient's brain, is better than intensive medical therapy alone.

The study is called the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracrainal Stenosis or SAMMPRIS. The study is the first to look at the long-term benefits of the Wingspan stent, the only FDA approved stent designed to open clogged arteries in the brain.

Prior to the Wingspan stent, the options for treating stroke patients were limited. Blood-thinning medications are commonly used to treat narrowing of intracranial arteries, but studies have found that stroke patients who had severe artery blockages of 70 percent or more have a 22 percent chance of having another stroke within the first year, said Dr. Shyam Prabhakaran, section head of Cerebrovascular Disease and Neurological Critical Care at Rush

Dr. Demetrius Lopes, neuroendovascular surgeon at Rush, was the first physician in Illinois to use the Wingspan stent. The catheterization procedure involves carefully threading a hair-like filament from a tiny incision on the inside of the thigh through the body's arteries and veins up to the patient's brain. After reaching the site of the blockage, the plaque-filled brain vessel is first opened using a microscopic balloon that is inflated, pressing aside the blockage. The stent is placed to hold the plaque against the artery wall and keep the blood flowing through the brain.

Rush has the largest experience with the Wingspan stent in Chicago. The stent has been quite effective in preventing recurrent strokes in more than 100 cases, said Lopes.

A preliminary study released last year that was funded by the NIH found that the Wingspan stent was successfully deployed in nearly all cases and significantly reduced arterial blockages in the short term. But data on the long-term benefit of the stent, compared to medical treatment alone, were inconclusive, prompting the launch of the SAMMPRIS trial.

A randomized trial such as SAMMPRIS is one of the most powerful scientific tools to bring us definitive answers, said Lopes. The results from this trial will improve the management of patients at risk for stroke.

In addition, the study will determine the effectiveness of intensive medical management of underlying conditions such as high cholesterol and high blood pressure. There has not been a landmark study looking at how the aggressive treatment of these underlying conditions can benefit stroke victims.

This is a seminal study, one funded by the NIH and having significant implications on future management of patients with narrowed arteries in the brain, said Prabhakaran. It will determine whether we should be offering stenting as a primary treatment of narrowed arteries or whether medications are sufficient.

The five-year SAMMPRIS study plans to enroll 764 patients from approximately 60 sites in the Unites States. Intensive medical therapy for all participants will consist of aspirin, clopidogrel (a blood thinner), and aggressive risk factor management primarily targeting blood pressure and cholesterol. Approximately half of the patients in the trial, selected randomly, will have a stent placed. Study participants will be evaluated by a neurologist every four months and will meet with internists who will manage the vascular risk factors.

To be eligible for this trial, patients must be between the ages of 30 and 80 years, have had a stroke or TIA within 30 days, and have stenosis (narrowing) of a major intracranial artery (blood vessel in the brain).

Thrombolysis therapy of benefit 9 hours post-stroke

Mon, 09 Feb 2009 12:01:45 PST

( from http://www.rxpgnews.com ) Some patients who suffer a stroke as a result of a blockage in an artery in the brain may benefit from a clot-busting drug nine or more hours after the onset of symptoms. The findings are published in the online edition of Radiology.

"Stroke is the third leading cause of death in the U.S.," said the study's lead author, William A. Copen, M.D., Director of Advanced Magnetic Resonance Neuroimaging at Massachusetts General Hospital (MGH) in Boston. "Every hour that we can add to the treatment window would allow vastly more stroke patients to be treated with potentially life-saving therapy."

The most common type of stroke is called ischemic stroke. These strokes occur when a blood clot blocks a blood vessel supplying blood to the brain. Some ischemic strokes can be treated with thrombolytic, or clot-busting, therapy using tissue plasminogen activator (t-PA), which helps dissolve the blockage. However, the window of opportunity to safely administer the medication is generally considered to be just three hours. Because few patients get to the hospital to be diagnosed and treated within that time frame, fewer than seven percent of patients receive the drug.

In this retrospective study, researchers analyzed the test results of 109 ischemic stroke patients at MGH. The testing methods included two different MRI scanning techniques: perfusion MRI, which measures blood flow in the brain, and diffusion MRI, which measures the movement of water molecules in tissue.

"Comparing the lesions that we see in these two MR images reveals which areas of the brain are threatened by a lack of blood flow, but could still be salvageable," Dr. Copen said. "A mismatch between the lesions suggests that a patient might still benefit from thrombolytic therapy."

In the study, most patients with blockage in a proximal artery, close to the base of the brain, continued to demonstrate a diffusion-perfusion mismatch between nine and 24 hours after the onset of their strokes.

"Patients who have a mismatch have been successfully treated up to nine hours after stroke onset, which is already much longer than the guidelines allow, Dr. Copen said. "Our findings suggest a need for a clinical trial to measure the effectiveness of thrombolytic therapy more than nine hours after the onset of an ischemic stroke."

A mesh-like network of arteries helps wih blood flow to the brain after a stroke

Fri, 30 Jan 2009 14:30:03 PST

( from http://www.rxpgnews.com ) A grid of small arteries at the surface of the brain redirects flow and widens at critical points to restore blood supply to tissue starved of nutrients and oxygen following a stroke, a study published this week has found.

Surface arteries brain dive into the brain to feed capillaries. The mesh-like network adjusts to restore normal supply when blood slows after a stroke.

“This is optimistic news,” said David Kleinfeld, a physics professor at the University of California, San Diego, whose group studies blood flow in animal models of stroke.

Damage from stroke can continue for hours or even days as compromised brain tissue surrounding the core injury succumbs to deprivation of oxygen and nutrients.

“This is the area doctors are trying to protect after a stroke,” said Andy Shih, a postdoctoral fellow in Kleinfeld’s group who conducted the experiments. “Those neurons are teetering on the edge of death and survival.”

Previous work with animal models had found that blood flow can persistently slow in the aftermath of a stroke, which would hinder the delivery of drugs that might help recovery. But those studies only measured the speed of the blood.

By measuring both the speed of blood cells moving through individual small arteries and the diameters of the same vessels, the scientists found that the arteries dilate to maintain a constant delivery of blood cells.

“You find that the velocity has gone down, but that the diameter—on average—exactly compensates,” Kleinfeld said.

Patrick Drew and Philbert Tsai in Kleinfeld’s group, and Beth Friedman and Patrick Lyden, MD, of the neuroscience department at UC San Diego’s School of Medicine co-authored the paper. Lyden, whose contributions to a 1995 study proved that the drug tPA can reverse the course of stroke when administered promptly, also directs the UC San Diego Stroke Center. The Journal of Cerebral Blood Flow and Metabolism published their new finding online January 28.

Key to this resilience, it seems, is the structure of the vascular network overlying the brain.

“Vessels on the surface of the brain have a mesh-like architecture,” Kleinfeld said. “One consequence of that is that it operates like a grid system that redistributes “current flow as you need it.”

“City traffic freezes a lot less than you would think because once a street gets bogged down, you can move over to another street,” he said. “This seems to be what happens on the surface of the brain.”

Flows through the surface vessels reversed and stalled, as previously observed, but those changes helped to redistribute blood to ensure a steady supply though vessels that penetrate into the brain.

Shih focused his measurements on small arteries, called arterioles, at the point where they dive into the brain to supply a discrete patch of the cortex, a juncture that is vulnerable to occlusions that can cause microstrokes this group’s previous work has found.

“These are extremely important. A single penetrating arteriole will feed a column of tissue,” Shih said. “These are bottlenecks in flow.”

The penetrating vessels neither reversed nor stalled, even though many connected to loops and bridges in the vascular network that could have allowed that to happen. Even when the pressure dropped permanently as a result of stroke damage, wider lanes allowed the network to deliver red blood cells at the same rate.

“Diameter is the major determinant to how blood actually flows through vessels. Open up a blood vessel a little bit and you’ll have a huge change in the amount of blood that goes through,” Shih said. “Blood flow comes back, and it seems that these vessels are very resistant to the stroke. They function quite normally.”

Blocking LRP1 can reduce toxic effects of clot-busting drug tPA

Sat, 24 Jan 2009 16:35:30 PST

( from http://www.rxpgnews.com ) Since the introduction of the life-saving clot-busting drug tPA more than a decade ago, evidence has been accumulating that tPA (tissue-type plasminogen activator) can be a double-edged sword for a brain affected by stroke. Although it remains the only FDA-approved treatment for acute stroke, tPA can also contribute to inflammation and brain cell damage.

Scientists at Emory University School of Medicine are testing strategies for blocking LRP1, a molecule that appears to transmit inflammation signals triggered by tPA. They have found that in mice, genetically removing LRP1 from certain brain cells called microglia softens tPA's impact on the brain.

The results, published online this week by the American Journal of Pathology, suggest that blocking tPA's toxic effects could make it safer and allow doctors to use it more often on patients experiencing a stroke.

"tPA is a protein released naturally by the body in response to a blood clot," says Manuel Yepes, MD, PhD, assistant professor of neurology at Emory University School of Medicine. "But it's clearly not just lysing the clot."

Doctors in community hospitals can often be reluctant to administer tPA to patients who appear to be having a stroke, Yepes says. One reason is that tPA has been shown to increase the risk of bleeding in the brain, he says.

Researchers have shown that tPA treatment increases the permeability of the blood-brain barrier, and that it can cross from the blood vessels into the brain tissue, generating inflammation. tPA targets cells called microglia, which are similar to white blood cells of the immune system, although they live in the brain.

"Our strategy was to show that by blocking LRP1, you can prevent the inflammatory response to tPA," Yepes says. "This can be done either genetically, by deleting LRP1, or perhaps pharmacologically."

Yepes and his colleagues are now testing a natural inhibitor of LRP1 called RAP in the laboratory. Co-treating or even pre-treating stroke patients with RAP might soften tPA's effects.

Researchers had previously been unable to examine the effects of deleting LRP1, a protein involved in transporting cholesterol and other molecules around the brain, because mice completely lacking the gene die in the womb.

Yepes and his colleagues collaborated with Dudley Strickland, PhD, professor of surgery and physiology at University of Maryland School of Medicine, who provided mice deficient in LRP1 in macrophages (white blood cells) and microglia only.

The authors showed that the genetically altered mice have half the number of activated microglia in the brain after treatment with tPA. In addition, the volume of brain tissue damaged by a simulated stroke was cut in half in the genetically altered mice.

Smokers with family history of brain aneursyms at high risk of stroke

Thu, 01 Jan 2009 12:26:38 PST

( from http://www.rxpgnews.com ) A new study shows that people who are smokers and have a family history of brain aneurysm appear to be significantly more likely to suffer a stroke from a brain aneurysm themselves. The research is published in the December 31, 2008, online issue of Neurology®, the medical journal of the American Academy of Neurology and will appear in the January 6, 2009, print issue of Neurology.

Subarachnoid hemorrhage, a type of bleed from a brain aneurysm which leads to a stroke, is deadly in about 35 to 40 percent of people.

In the study, scientists looked at 339 people who suffered a stroke from a brain aneurysm and 1,016 people who had not had a stroke due to an aneurysm. Current smokers made up half of the group that had a stroke. The other half had never smoked or had smoked in the past.

The research found people who smoked and had a family history of stroke were more than six times more likely to suffer a stroke than those who did not smoke and did not have a family history of stroke or brain aneurysm. The study also found that people with a family history of stroke could cut their risk by more than half by quitting smoking. The results were the same regardless of high blood pressure, diabetes, alcohol use, body mass index and education level.

"While all people should be advised to quit smoking, our findings suggest that there is an interaction so that if you smoke and you have a family history of aneurysms, you are at an extremely high risk of suffering a stroke from a ruptured brain aneurysm," says study author Daniel Woo, MD, with the University of Cincinnati in Ohio and member of the American Academy of Neurology.

UT faculty members win American Heart Association awards for advancing research

Tue, 23 Dec 2008 05:00:00 PST

( from http://www.rxpgnews.com ) Faculty members at The University of Texas Health Science Center at Houston (UTHSC-Houston) were honored for their work in the fight against heart disease at the 2008 American Heart Association's Scientific Sessions in New Orleans. Heart disease is the nation's No. 1 killer.

UT faculty members recognized were: Nobel Laureate Ferid Murad, M.D., Ph.D., director emeritus of The Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases (IMM), a part of the UTHSC-Houston; John Holcomb, M.D., director of the Center for Translational Injury Research at the UTHSC-Houston; and Raffaella Lombardi, M.D., Ph.D., IMM postdoctoral fellow. The AHA scientific sessions were Nov. 8 -12.

Murad was named one of 13 Distinguished Scientists for 2008 by the American Heart Association. The prestigious award was created to honor researchers whose work has advanced the understanding of cardiovascular disease and stroke.

Murad found that nitroglycerin and several related heart drugs induce the formation of nitric oxide and that this gas acts to increase the diameter of blood vessels in the body, according to the American Heart Association. He shared the 1998 Nobel Prize in Physiology or Medicine with Robert Furchgott and Louis Ignarro for their major discoveries involving nitric oxide as a unique signaling molecule in the cardiovascular system.

Nitric oxide is one of the most important signaling molecules produced within our body. Dr. Murad's contributions to the field have revolutionized the concept of cell signaling by a gaseous molecule. Potential applications are far-reaching across multiple organ systems. Discovery of this pathway has allowed new therapeutic strategies to control blood pressure, correct conditions of endothelial dysfunction and even treat erectile dysfunction, said Nathan Bryan, Ph.D., assistant professor of molecular medicine at the IMM.

Murad completed his undergraduate work at DePauw University and received his M.D. and Ph.D. from Case Western Reserve University. He completed a medical residency at Massachusetts General Hospital and a fellowship at NIH in the Heart Institute.

Holcomb received the 2008 Lifetime Achievement Award in Trauma Resuscitation Science, which was established in 2003 to recognize leaders in this field. Holcomb's contributions to trauma medicine include increased hemorrhage control through dressings, tourniquets and intravenous methods, as well as trauma informatics and systems.

Each year the American Heart Association selects one surgeon to receive a Lifetime Achievement award for their contributions to the resuscitation of critically ill or injured patients. Dr. Holcomb, while serving in the U.S. Army (now retired) made significant contributions to the understanding and treatment of injured patients in war zones as well as civilian trauma. His contributions have led to a new paradigm in transfusion of patients sustaining blood loss. He well deserves this recognition, said Richard Andrassy, M.D., professor and chairman, the Denton A. Cooley, M.D., Chair in Surgery and the Jack H. Mayfield, M.D. Distinguished University Chair at The University of Texas Medical School at Houston.

Holcomb is past commander of the United States Army Institute of Surgical Research at the Brooke Army Medical Center in San Antonio. He finished his undergraduate work at Centenary College and received his degree of medicine at the University of Arkansas Medical School in Little Rock. He completed an internship and residency in general surgery at the William Beaumont Army Medical Center in El Paso.

Lombardi won the 2008 Louis N. and Arnold M. Katz Basic Science Research Award Prize for Young Investigators, which is given to the best scientific presentation at the annual scientific sessions of the American Heart Association.

Lombardi presented a manuscript describing the origin of the fat cells in the heart in a disease condition referred to as arrhythmogenic right ventricular cardiomyopathy, which is an important cause of sudden cardiac death in the young, especially athletes. In this disease, which is a genetic disorder, excessive fat cells replace cardiac myocytes in the heart, particularly the right side of the heart. She and her colleagues showed that fat cells originate from the stem cells in the heart that through a unique mechanism convert to fat cells in the presence of genetic mutations.

The Katz Award is the most prestigious award given to young investigators in basic cardiovascular research by the American Heart Association, said Ali Marian, M.D., professor and director of the Center for Cardiovascular Genetic Research at the IMM. The work (of Lombardi) could lead to the development of new therapies aimed at preventing the cardiac stem cells from switching a muscle fate to a fat cell fate and therefore, prevention of this potentially deadly disease.

Lombardi received her medical degree and clinical training in internal medicine and cardiology at Federico II University of Naples, Italy. She joined Marian's research group in the IMM three years ago and earned a doctorate in clinical physiopathology and experimental medicine from Federico II University of Naples during this period.

University of Miami biomedical engineer

Wed, 17 Dec 2008 05:00:00 PST

( from http://www.rxpgnews.com ) CORAL GABLES, FL (December 17, 2008)-Baruch Barry Lieber, Ph.D., professor of biomedical engineering at the University of Miami College of Engineering and professor of radiology at the University of Miami Miller School of Medicine, has received a grant from the National Institute of Neurological Disorders and Stroke (NINDS), to support research studies that offer promise in the treatment of brain aneurysms.

The $1.9 million grant administered over a period of five years will help fund the development and optimization of assistive technology for a device created by Lieber to help heal brain aneurysms.

Dr. Lieber's project addresses the important need for methods to treat brain aneurysms, said Eugene Golanov, M.D., Ph.D., program director of NINDS. Although there are clinically available techniques to prevent aneurysm rupture, they are not ideal for all patients. We are optimistic that Dr. Lieber's work will lead to a useful alternative therapy.

The project for which Lieber won the award is titled, Flow Divertors to Cure Cerebral Aneurysms. The focus of the research is to develop a tubular mesh-like device, which can be placed into cerebral arteries via catheters, to reduce the blood flow in an aneurysm, while keeping the arteries open to supply oxygen to the brain tissue.

Slowing down the blood flow within the aneurysm leads to natural clotting, which prevents rupture of the aneurysm and elicits a healthy scar-response from the body, thus restoring the diseased arterial segment to its normal state, explained Lieber.

Dr. Lieber, is a professor of biomedical engineering in UM's College of Engineering, with a secondary appointment in the Department of Radiology at the Miller School of Medicine. He works in conjunction with the Vascular Biology Institute (VBI) on the medical campus. The VBI deals with all aspects of vascular function in health and disease with a focus on angiogenesis, coronary artery disease, aneurysm, and stroke, explained Keith Webster, Ph.D., director, professor and Walter G. Ross chair of the VBI.

Dr. Lieber spearheads the aneurysm and stroke studies and has developed technology that is changing the field and will directly impact clinical treatments, said Webster. We are working with Dr. Lieber's group within the VBI combining our novel gene and stem cell technologies with his cutting edge bioengineering approaches to develop new treatments that can be rapidly translated into clinical applications.

The collaboration between the College of Engineering and the Miller School of Medicine is part of an ongoing effort to forge interdisciplinary cooperation, said Ozcan Ozdamar, PhD., professor and chairman of the University of Miami Department of Biomedical Engineering.

Dr. Lieber is an outstanding biomedical engineer and researcher with an established record, said Ozdamar. His award is the result of our continuing collaboration between the College of Engineering and the Miller School of Medicine, aimed at finding innovative solutions to challenging medical problems

Dr. Henry Barnett becomes first person outside Europe to receive Karolinska Stroke Award

Wed, 29 Oct 2008 04:00:00 PST

( from http://www.rxpgnews.com ) Dr. Henry JM Barnett, London, Ontario, receives the Karolinska Stroke Award for Excellence in Stroke Research. The prize amounts to 100,000 SEK. The laureate will receive the prize from the President of Karolinska Institutet Harriet Wallberg-Henriksson during the Karolinska Stroke Update meeting in Stockholm November 17, 2008. Barnett is the first non-European to receive this prestigious award. The Karolinska Institutet also awards the Nobel Prize annually.

Barnett's key research field is prevention of stroke. For younger colleagues, he will be primarily remembered as an enthusiastic coordinator of the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Together with a European study of similar design this trial provided the scientific evidence for operation on tight atherosclerotic manifestations on the carotid artery of the neck, since then one of the most important interventions to prevent recurrent stroke after transient or mild cerebrovascular warning symptoms.

Before the NASCET study, Barnett was leading another extensive trial, with quite a different outcome. In North America, and some other medical centres in the world, clinics were established to perform extracranial-intracranial (EC-IC) bypass surgery, in patients with total occlusion of one of the major supplies to the brain, the internal carotid artery. Through an opening of the skull bone, arteries on the outside of the skull were connected with those on the surface of the brain. The EC-IC bypass study showed that these operations did not benefit patients and in the mid 1980s, these operations were almost totally stopped. Today we know that before any conclusions can be made on the severity of an occluded carotid artery, an evaluation of alternative (collateral) blood flow supply to the brain is essential.

Even earlier, in 1970, Barnett was leading the Canadian Aspirin Trial which established, for the first time, that any antiplatelet drug could prevent diseases (in this case stroke) due to arterial thrombosis.

Barnett was born in Newcastle upon Tyne in England and moved with his parents to Canada as a child. He entered medicine at the University of Toronto where he graduated in 1944. He did his junior rotating internship at the Toronto General Hospital and later completed training in neurology in Toronto in 1950. After two years at Queen Square in London, UK, and later a research assistant in Oxford, he obtained a fellowship from the Royal College of Physicians and Surgeons of Canada (F.R.C.P.(C.)). From 1952 to 1967 he was neurologist at the Toronto General Hospital and from 1966 to 1969 Chief of the Division of Neurology at Sunnybrook Medical Centre. In 1969 he was invited to become the Chief of the Division of Neurology at The University of Western Ontario and Victoria Hospital in London, Ontario. From 1974 to 1984 he served as Chairman of the Department of Clinical Neurological Sciences at The University of Western Ontario. In 1986, he co-founded the Robarts Research Institute and was named its first Scientific Director.

Barnett's extraordinary contributions to stroke research have changed the management of millions of stroke patients. The implementation of his research has prevented an unaccountable number of strokes. He has shown the strength of research by revealing that some routinely used procedures were supported by science, others were not.

For these contributions, Dr. Henry JM Barnett is awarded the Karolinska Stroke Award for Excellence in Stroke Research in 2008.

Scientist plans to test for blood pressure genes affected by age

Wed, 24 Sep 2008 04:00:00 PST

( from http://www.rxpgnews.com ) A geneticist at The University of Texas Health Science Center at Houston plans to scan the genomes of about 4,000 people in the hopes of finding out why blood pressure often increases as young adults age.

The two-year study by principal investigator Myriam Fornage, Ph.D., is funded with a new $1.1 million grant from the Genes, Environment and Health Initiative (GEI) of the National Institutes of Health. The grant was one of six announced today during the second round of funding from the program aimed at finding genetic factors that influence common disorders.

High blood pressure is the single most important predisposing factor to cardiovascular disease, said C. Thomas Caskey, M.D, director/chief executive officer of The Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases (IMM), a part of the UT Health Science Center. This research could lead to the identification of genes through which environmental factors such as aging act to accelerate disease. Knowledge of these genes opens new opportunities for therapeutic targets.

The GEI researchers receiving grants will use genome-wide association studies. In such studies, researchers rapidly scan markers across the complete sets of DNA, or genomes, of large groups of people to find genetic variants associated with a particular disease, condition or trait.

According to Peter Doris, Ph.D., an IMM professor, Age is clearly the most important environmental risk factor for high blood pressure. What is novel and potentially powerful about Dr. Fornage's project is the focus on age and blood pressure interaction.

Fornage said little is known about the genetic cause of high blood pressure and that her study is among the first to look at blood pressure genes in the context of age. We're trying to determine how genes influence the gradual rise in blood pressure experienced by many people as they move from being a young adult to a middle-aged person, she said.

The study will begin by examining the genomes of about 4,000 people who were recruited into a research project in the mid-1980s and who have had their blood pressure checked periodically. The project is called the Coronary Artery Risk Development in Young Adults (CARDIA) Study and participants were between 18 and 30 when it began.

To confirm the findings, scientists from the Human Genetics Center at The University of Texas School of Public Health will attempt to replicate the results with participants in: the Bogalusa (La.) Heart Study; the Atherosclerosis Risk in Communities Study (ARIC); and the Rochester (Minn.) Family Heart Study.

D. Michael Hallman, Ph.D., an assistant professor at the UT School of Public Health, will coordinate tests with the Bogalusa (La.) Heart Study. Alanna Morrison, Ph.D., an associate professor at the UT School of Public Health, will coordinate tests with the Rochester (Minn.) Family Heart Study.

Our ultimate goal is to discover pathways that could be targeted for therapeutic intervention, Fornage said.

Thrombolysis in stroke- upto 4 and 1/2 hours

Mon, 15 Sep 2008 12:34:15 PST

( from http://www.rxpgnews.com ) The time span in which treatment should be given for acute ischaemic stroke – i.e. stroke caused by a clot or other obstruction to the blood supply – can be lengthened. This according to a study from the Swedish medical university Karolinska Institutet, the results of which can bring about more effective and safer treatments for stroke sufferers.

In the event of acute ischemic stroke, treatment with 'clot-busting' drugs – thrombolysis – should be administered as early as possible. Failure to do so might leave the treatment doing harm than good since it increases the danger of haemorrhage. Prevailing praxis is for thrombolysis to be given only to patients who reach hospital within three hours after the onset of stroke.

However, an international study led by Professor Nils Wahlgren at Karolinska Institutet now shows that it is safe to administer the treatment up to four and a half hours after the stroke.

The researchers compared 11,865 patients treated within three hours of stroke with 644 patients who, for various reasons, were treated within three to four and a half hours afterwards. The results show that the risk of haemorrhage complications and death was not significantly higher for the later treatment. Nor was there any difference between the two groups in the percentage of patients displaying impaired functionality in everyday activities three months after stroke.

"The data we are now publishing will make it possible for many more patients to receive thrombolysis," says Professor Wahlgren. "This is important, because it'll not only alleviate their suffering, but also help to reduce the costs of stroke for society."

Possible changes to the European guidelines for the treatment of stroke will be under discussion at Karolinska Stroke Update, a conference due to be held in Stockholm on 16-18 November. Here, consideration will also be taken of the results of another, as yet unpublished, randomised study co-led by Professor Wahlgren.

UIC leads multi-center study to evaluate blood flow and stroke risk

Tue, 09 Sep 2008 04:00:00 PST

( from http://www.rxpgnews.com ) The University of Illinois at Chicago has been awarded a five-year, $2.1 million grant from the National Institute of Neurological Disorders and Stroke to lead a multi-center study to assess blood flow and stroke risk.

Ischemic strokes -- the type caused by clots rather than bleeds in the brain -- account for 80 percent of all strokes and represent a major source of death and disability. They are often caused by atherosclerosis, a build-up of plaque inside the walls of blood vessels.

Advances in endovascular techniques, such as threading a catheter to open up a blockage, or placing a stent in a vessel, provide new treatment options for patients with stroke. But these interventions carry risks, and physicians don't always know which patients are appropriate candidates for these procedures.

There's been a lot of emphasis in prior medical research on the type of stroke that affects the anterior circulation, or blood supply to the major lobes in the front of the brain, says Dr. Sepideh Amin-Hanjani, UIC assistant professor of neurological surgery and principal investigator of the study.

But there's another set of arteries that supply the back part of the brain, including the brainstem, which is a smaller, but in some ways, a much more functionally important part of the brain with a lot of important real estate, she said.

Even a very small stroke in this area of the brain can have very devastating consequences, Amin-Hanjani said.

Until recently, it has been difficult for researchers to measure blood flow in the vertebral arteries to the back of the brain. But they hypothesize that patients with vascular disease in these arteries have low blood flow and are at higher risk of stroke.

The study will enroll 80 patients at five sites who have first-time stroke symptoms caused by 50 percent or greater blockage of the arteries leading to the back of the brain.

Patients will receive standard brain imaging with MRI or CT, imaging of the blood vessels, and possible medication therapy, which might include aspirin, anti-cholesterol medication, or blood pressure lowering medication.

As part of the study, patients will additionally undergo magnetic resonance (MR) perfusion and quantitative magnetic resonance angiography (QMRA) that measures blood flow using NOVA technology developed by UIC neurosurgeon Dr. Fady Charbel. The Noninvasive Optimal Vessel Analysis measures the volume of blood flow, direction, and provides a four-dimensional view of the shape and form of blood flow.

Patients will be imaged when they are first enrolled in the study and six and 12 months later. They will be monitored monthly for any recurrent symptoms that would suggest a stroke.

After following the participants for a minimum of one year, researchers will compare the blood flow of patients who had a stroke since their initial symptoms with those patients who did not have stroke.

We hypothesize that patients who have better blood flow to their brains are going to be the ones that don't have new strokes, and those that have low blood flow on their brain scans will be at higher risk of having strokes, said Amin-Hanjani.

If this is demonstrated, then patients with low blood flow to their brain -- even when they first have stroke symptoms -- may be candidates for intervention such as stenting or angioplasty to increase blood flow, said Amin-Hanjani. At the same time, people who have stroke symptoms but normal blood flow could be reassured that their risk of stroke on medication therapy is low, and there may be no need for further intervention exposing them to unnecessary risk.

If we know who is at highest risk, we may be able to figure out who is going to benefit the most from interventional treatment, said Amin-Hanjani. Given that treatment such as stenting is not entirely risk free, it would be important to know that you're treating the highest risk population and offering them a benefit, rather than treating patients who may not need it.

Spreading depolarisation after a stroke- warning sign

Thu, 12 Jun 2008 10:06:06 PST

( from http://www.rxpgnews.com ) After a stroke, even unaffected areas of the brain are at risk – depolarization waves arise at the edges of the dead tissue and spread through the adjacent areas of the brain. If these waves are repeated, more cells die. This has previously been observed only in animal studies.

A clinical study at the university hospitals of Heidelberg and Cologne along with the Max Planck Institute of Neurological Research in Cologne has shown for the first time that this phenomenon occurs after a stroke in humans and is a warning sign that more nerve cells will die. The study, published in June 2008 in the renowned journal “Annals of Neurology,” may allow to translate more than 60 years of experimental research for the diagnosis and therapy of stroke patients.

More than 150,000 people a year in Germany suffer a cerebral stoke, the third most frequent cause of death in industrialized countries. When deposits clog vessels to the brain, some areas of the brain do not receive sufficient oxygen and the tissue dies. Depending on the size of the area affected, the patients may die or suffer permanent damage such as paralysis.

Spreading depolarizations first proven in stroke patients

The depolarization waves in the brain – known as cortical spreading depression (CSD) – have been studied only experimentally since the 1940s. Many features are thus known from animals – the waves of depolarization that can spread out at a speed of two to five millimeters per minute are followed by silence – brain activity comes to a halt for a short time. In this time, the nerve cells recover. “The impact of these waves is several times greater for nerve cells than an epileptic seizure,” says Professor Dr. Rudolf Graf from the Max Planck Institute of Neurological Research and co-founder of the international study group COSBID (Cooperative Study on Brain Injury Depolarisations).

“After the stroke, circulation in the tissue surrounding the affected area of the brain is initially poor, but it can still be saved,” explained Dr. Christian Dohmen of the Neurology Department at Cologne University Hospital. The spreading depolarizations additionally impair the metabolism of the weakened nerve cells. “The more frequently such waves occur, the longer the nerve cells require to recover, until finally they die off entirely,“ says the main author of the study. To what extent the brain is damaged after a stroke depends thus on the number of these spreading depolarizations. This correlation is becoming apparent in humans as well.

Know-how from 60 years of research can now be used for treating stroke patients

The spreading depolarizations, which also occur after head injuries or hemorrhages, can be measured only on the surface of the brain. For this study, the physicians therefore selected 16 patients whose brain had to be partially exposed due to a life threatening swelling of brain tissue. Electrodes were applied to the surface of the brain around the affected tissue (electrocorticography), the incisions were closed, and brain waves were measured for five days. All patients were in an artificial coma during this period due to their serious condition.

"Our study puts an end to the discussion as to whether these waves also occur in a human brain following a stroke,“ says Dr. Oliver Sakowitz, physician at the Department of Neurosurgery of the University of Heidelberg Hospital and co-author of the study. Now comes the question of how to prevent or at least contain them. “As they cause additional damage to the weakened tissue surrounding the stroke area, it is conceivable that we could prevent further damage by suppressing the waves,” said the neurosurgeon.

In previous experimental studies on animals, a few therapy approaches were already developed which physicians can now apply. “The spreading depolarizations are a warning sign that other areas of the brain are at immediate risk and may be also useful as diagnostic measures,” says Dr. Sakowitz. In a follow-up study on a larger number of stroke patients, the COSBID team under the direction of Dr. Christian Dohmen wants to clarify whether cortical spreading depression has an influence on the extent of sequelae such as paralysis.

Anti-estrogen drug therapy reduces risk of invasive breast cancer in older women

Tue, 10 Jun 2008 04:00:00 PST

( from http://www.rxpgnews.com ) New analysis of a drug approved for osteoporosis prevention and treatment has provided definitive evidence that the medication is also effective as a breast cancer preventative for certain cancers. Women who took the drug raloxifene were less likely to develop invasive, estrogen-receptor (ER) positive breast cancer compared with women who did not take the drug. The results of the randomized controlled trial will be published in the June 10 online issue of the Journal of the National Cancer Institute.

Breast cancer is the most common cancer among women. In 2008, to date, 182,460 new cases of female breast cancer have been diagnosed and 40,480 women have died due to breast cancer (National Cancer Institute).

Raloxifene is a selective estrogen receptor modulator (SERM), which means that the drug has estrogen-like effects on some tissues, such as bone, but anti-estrogen effects on other tissues such as breast. Previous data from the RUTH (Raloxifene Use for The Heart) Trial, which involved more than 10,000 post-menopausal women participants around the world who had an increased risk of coronary heart disease, showed that the drug did not protect against heart disease but it did reduce the risk of invasive breast cancer by 44 percent. The drug is currently approved by the FDA for the prevention and treatment of osteoporosis in postmenopausal women, and invasive breast cancer risk reduction in postmenopausal women with osteoporosis or at high risk for breast cancer.

In this paper, researchers report that, regardless of age, prior hormone use or baseline breast cancer risk, raloxifene reduced the risk of hormone responsive (ER-positive) breast cancers by at least 50 percent for at least 8 years. Most postmenopausal women with breast cancer have this kind of breast cancer.

Non-invasive cancers confine themselves to the ducts or lobules and do not spread to the surrounding tissues in the breast or other parts of the body. They can, however, develop into or raise the risk for a more serious, invasive cancer. Invasive cancers are more aggressive and have started to break through normal breast tissue barriers and invade surrounding areas.

This research gives older women facing certain medical decisions another option, explained principal investigator Elizabeth Barrett-Connor, M.D., distinguished professor and Chief, Division of Epidemiology, Department of Family and Preventive Medicine, and a member of the Cancer Prevention and Control Program, UC San Diego School of Medicine. For example, if a woman at risk for osteoporosis is considering taking medication, and has no history of blood clots or stroke, raloxifene might be a more appealing option due to its protective role in invasive breast cancer.

The RUTH trial, the world's largest study of women and heart disease, was a randomized, blinded, placebo-controlled trial conducted at 177 sites, in 26 countries, on five continents. Between June 1998 and August 2000, 10,101 postmenopausal women with coronary heart disease or several heart disease risk factors were randomly assigned to raloxifene or to placebo and followed for a median of 5.6 years. The 5,044 women who took raloxifene had a 55 percent reduction in risk of developing invasive ER-positive breast cancer as compared to the 5,057 women who took placebo.

The initial results of the RUTH trial were published in 2006. The reduction in breast cancer risk was consistent with findings from other trials that involved women who did not have heart disease. However, women who took raloxifene in the RUTH trial had an increased incidence of blood clots and fatal strokes compared to those who took placebo. Thus, the researchers concluded that women considering use of raloxifene need to weigh the risks and benefits.

Study author Deborah Grady, M.D., M.P.H., of the University of California, San Francisco, and colleagues examined the RUTH trial data in more detail in order to investigate the specific types and stages of breast cancer affected by raloxifene, as well as the timing of its action and the types of patients it can help.

In this study, we looked at whether raloxifene would be more effective in some subgroups of women than others, but found that the relative benefit was the same, regardless of breast cancer risk, said Grady. Like any therapy, the risk needs to be balanced with the side effects, which for raloxifene include blood clots and fatal stroke.

But these findings are important because few drugs actually reduce the risk of breast cancer. noted Grady. Also raloxifene has been on the market for nearly a decade with good, long term safety data, said Barrett-Connor.

Researchers say women who would have the best risk-benefit ratio would be those at high risk of breast cancer, who have a 30 to 50 percent chance of getting breast cancer in the next five to ten years, and low risk of venous thrombosis and stroke. A reduced risk of spine fractures would be an additional benefit.

New guidelines for treating resistant hypertension

Fri, 06 Jun 2008 04:00:00 PST

( from http://www.rxpgnews.com ) BIRMINGHAM, Ala. -- Resistant hypertension, blood pressure that remains above goal despite taking three antihypertensive medications or high blood pressure that is controlled but requires four or more medications to do so, may benefit from specialized diagnostic and therapeutic treatment by health care providers according to guidelines issued by the American Heart Association and co-authored by UAB physicians.

Lead author David A. Calhoun, M.D., professor of medicine in the UAB Division of Cardiovascular Disease, and colleagues said successfully treating resistant hypertension requires patients to modify lifestyle factors that contribute to treatment resistance, including using less salt, losing weight and drinking less alcohol. It also requires physicians to better diagnose and treat secondary causes of high blood pressure and more effectively use multiple-drug treatments. This is the first consensus statement to define resistant hypertension and recommend an approach for evaluation and treatment.

Calhoun said while it is not known how many people in the U.S. with high blood pressure have resistant hypertension clinical trials suggest it may as high as 20 to 30 percent.

Older age and obesity are two of the strongest risk factors associated with resistant hypertension and unfortunately, with an aging and increasing heavy population, we can anticipate resistant hypertension becoming more and more common, he said. And people need to recognize the importance of blood pressure control. Persons with resistant hypertension are at increased risk for cardiovascular diseases, including heart attacks and strokes.

Calhoun and colleagues emphasize in the statement that effective use of diuretics is essential for treatment of resistant hypertension. Calhoun said they recommend that a long-acting diuretic be part of the treatment regimen of all patients with resistant hypertension in order reduce fluid retention and thereby blood pressure. He added that some patients may also benefit from adding mineralocorticoid receptor antagonists (MRAs) to their treatment regimens. MRAs have traditionally been used to treat a condition called primary aldosteronism, which is found in about 20 percent of patients with resistant hypertension. However, recent clinical studies indicate that MRAs may be useful in treating resistant hypertension even in the absence of demonstrable aldosterone excess.

The benefit of MRAs for treating resistant hypertension has been recently appreciated, he said. Hypertension specialists are using them more commonly, but they are probably not being routinely used by other physicians. Prescription of MRAs does require biochemical monitoring, particularly measurement of serum potassium levels, which does limit there use.

Calhoun said it is important to note that uncontrolled high blood pressure and resistant hypertension are not the same and effectively evaluating a patient to distinguish between the two possibilities is key to successful treatment.

High blood pressure readings can be caused by poor medication adherence, which is not the same as resistant hypertension, he said. Confirming treatment resistance is the first step in evaluating difficult-to-treat high blood pressure. It also is important to evaluate the condition correctly because often, patients with resistant hypertension have other medical conditions that complicate their blood pressure management. If a secondary cause of hypertension is identified such as obstructive sleep apnea, renal parenchymal disease, primary aldosteronism or renal artery stenosis, treating these disorders, which may require referral to a specialist, can improve blood pressure control.

USC awareded $12.4 million to spearhead stroke survivors rehabilitation project

Fri, 06 Jun 2008 04:00:00 PST

( from http://www.rxpgnews.com ) The University of Southern California is taking the lead to address rehabilitation therapy and how it can improve the quality of life for stroke survivors. Each year, about 700,000 people in the United States experience first or recurrent attacks of stroke.

About 65 percent of stroke survivors experience significant disability, such as the loss of use of one arm. This can lead to a reduced quality of life and loss of independence, says Carolee Winstein, director of the Motor Behavior and Neurorehabilitation Laboratory at USC.

More effective rehabilitation treatments could lessen the disability, caregiver burden and economic impact of stroke, says Winstein, a professor of biokinesiology and physical therapy.

To address the problem, the NIH-National Institute of Neurological Disorders and Stroke and the NIH-National Institute of Child Health and Human Development awarded Winstein $12.4 million for a five-year study of a promising physical therapy program for stroke patients who have lost movement in their upper limbs.

The trial will investigate the effectiveness of the Accelerated Skill Acquisition Program (ASAP), an intense and focused outpatient rehabilitation program that emphasizes activities-based training and resistance exercises, and includes 30 hours of one-on-one therapy early in the rehab process, within the first three months of the stroke. The ASAP program also uses motivational techniques to encourage patients to self-manage their therapy.

Patients in the study will be divided into three groups; the ASAP therapy group, an outpatient group receiving a similar amount of PT and a monitoring only out-patient therapy group. The ASAP and outpatient group will attend a one hour therapy session, three times a week for 10 weeks. Meanwhile, the monitoring only group will receive out-patient therapy for a frequency and duration prescribed by their referring physician.

Winstein's study is named I-CARE, for Interdisciplinary Comprehensive Arm Rehabilitation Evaluation (I-CARE) Stroke Initiative.

The I-CARE trial will link the USC School of Dentistry's Division of Biokinesiology and Physical Therapy with two other academic clinical research centers in the U.S.: the National Rehabilitation Hospital in Washington, D.C., led by co-principal investigator Alexander Dromerick, and the Emory University Center for Rehabilitation Medicine in Atlanta, Ga., led by co-principal investigator Steven Wolf. USC will serve as the primary project site and data management center.

I-CARE will also involve five Southern California physical rehabilitation sites: Cedars-Sinai Medical Center in Los Angeles, Casa Colina Centers for Rehabilitation in Pomona, Huntington Rehabilitation Medicine Associates in Pasadena, Long Beach Memorial Medical Center in Long Beach and Rancho Los Amigos National Rehabilitation Center in Downey.

The extensive study is expected to generate a wealth of useful data about stroke rehabilitation that could find use in trials of current and future experimental interventions such as pharmacological agents, gene therapy, stem cell implants and robot-assisted and direct cortical stimulation programs, Winstein says.

Surgeons announce advance in atrial fibrillation surgery

Mon, 07 Apr 2008 04:00:00 PST

( from http://www.rxpgnews.com ) Heart surgeons at Washington University School of Medicine in St. Louis report that by adding a simple 10-20 second step to an operative procedure they achieved a significant improvement in the outcome for the surgical treatment of atrial fibrillation (AF).

Reporting in the April issue of the Journal of Thoracic and Cardiovascular Surgery, the surgeons describe an enhancement to the Cox-Maze procedure, a surgical procedure that redirects wayward electrical impulses causing AF by creating precisely placed scars, or ablations, in the heart muscle. The Cox-Maze procedure is highly effective, offering the best long-term cure rate for persistent atrial fibrillation.

The surgeons added one ablation to the series of ablations typically made during the Cox-Maze procedure and that short step improved how well patients did after surgery. As a result, they recommend using this extra ablation in all patients undergoing the procedure.

The single additional ablation creates what we call a box lesion, explains Ralph J. Damiano Jr., M.D., the John Shoenberg Professor of Surgery at the School of Medicine. The box lesion surrounds and electrically isolates the pulmonary veins and the posterior left atrial wall from the rest of the left atrium. Our study shows excellent success when using the box lesion, and we recommend it for any patient with long-standing atrial fibrillation.

AF is the most common irregular heart rhythm and affects more than 2 million people in the United States. During atrial fibrillation, the upper chambers (atria) of the heart beat rapidly and quiver instead of contracting, drastically reducing the amount of blood they pump. AF can cause fatigue, shortness of breath, exercise intolerance, heart palpitations and stroke.

The area of the heart near the pulmonary veins is a common source of the irregular electrical impulses that can cause AF. Without the box lesion, in some patients this area could still support electrical signals that disrupt the regular contractions of the heart's upper chambers.

Led by Damiano, also chief of cardiac surgery at the School of Medicine and a cardiac surgeon at Barnes-Jewish Hospital, the Washington University surgeons revolutionized AF treatment in 2002 by helping develop a radiofrequency clamp that creates the ablation lines needed to reroute electrical impulses in the heart. The clamp directs radiofrequency energy into the heart muscle and creates a full-thickness scar.

The radiofrequency clamp procedure is quicker and easier than the original cut and sew Cox-Maze procedure, which was developed by James Cox, M.D., at Washington University in 1987. The original procedure relied on a complex series of 10 incisions in the heart muscle, creating a maze to channel errant electrical impulses where they should go. In the newer version, called Cox-Maze IV, most of these incisions were replaced by radiofrequency ablations, reducing the operation from an average of 90 minutes to about 30 minutes.

The current study involved two groups of patients with AF. One group underwent radiofrequency ablation-assisted Cox-Maze IV procedures without a box lesion and the other with a box lesion. The box lesion group had a 48 percent lower occurrence of atrial flutter and fibrillation in the first weeks after surgery. These patients also had shorter hospital stays (nine days on average) than patients who had the standard Cox-Maze IV procedure (average stay of 11 days).

Three months after surgery, 95 percent of patients who had the box lesion had no signs of AF, while only 85 percent of the patients who had the standard Cox-Maze IV procedure were free from AF. By six and 12 months postsurgery, all of the patients in the box lesion group were free from AF compared to 90 percent of the other group, although that difference was not statistically significant.

We also saw that the use of antiarrhythmic drugs was lower after three and six months in those who received a box lesion, Damiano says. These drugs can have serious side effects, and if patients can stop using them they often feel better. Overall, the use of the box lesion set was associated with shorter hospitalization, fewer medications and reduced recurrence of atrial fibrillation. We were very pleased with these results.

Compared to those without atrial fibrillation, people with the disorder are five times more likely to suffer from stroke and have up to a two-fold higher risk of death. For some patients, medications can control the abnormal heart rhythms and the risk of clotting associated with atrial fibrillation, but unlike the Cox-Maze procedure, the drugs usually do not cure the disorder.

Scientists find a key culprit in stroke brain cell damage

Thu, 27 Mar 2008 04:00:00 PST

( from http://www.rxpgnews.com ) Researchers have identified a key player in the killing of brain cells after a stroke or a seizure. The protein asparagine endopeptidase (AEP) unleashes enzymes that break down brain cells' DNA, scientists at Emory University School of Medicine have found.

The results are published in the March 28 issue of the journal Molecular Cell.

Finding drugs that block AEP may help doctors limit permanent brain damage following strokes or seizures, says senior author Keqiang Ye, PhD, associate professor of pathology and laboratory medicine at Emory.

When a stroke obstructs blood flow to part of the brain, the lack of oxygen causes a buildup of lactic acid, the same chemical that appears in the muscles during intense exercise. In addition, a flood of chemicals that brain cells usually use to communicate with each other over-excites the cells. Epileptic seizures can have similar effects.

While some brain cells die directly because of lack of oxygen, others undergo programmed cell death, a normal developmental process where cells actively destroy their own DNA.

The mystery was: how do the acidic conditions trigger DNA damage? Ye says. This was a very surprising result because previously we had no idea that AEP was involved in this process.

AEP is a protease, a class of enzymes that cuts other proteins. AEP is also called legumain because of its relatives in plants, and is found at its highest levels in the kidney, says Ye.

He and his co-workers had suspected that another class of proteases called caspases, involved in programmed cell death, controlled DNA damage after a stroke.

At first, he and postdoctoral fellow Zhixue Liu, PhD, thought the results of a critical experiment that led them to AEP were an aberration because the experiment was performed under overly acidic conditions.

But if you can repeat the mistake, it's not a mistake, Dr. Ye says, adding that follow-up work allowed them to set aside caspases as suspects and focus on AEP.

The researchers began by looking for proteins that stick to another protein called PIKE-L, which they previously had studied because of its ability to interfere with programmed cell death in brain cells.

They discovered that PIKE-L sticks to SET, a protein that other scientists had found regulates DNA-eating enzymes involved in programmed cell death. In addition, PIKE-L appears to protect SET from attack by AEP.

Liu and Ye found that a drug scientists use to mimic the acidic overload induced by stroke activates AEP, driving it to break down DNA in brain cells. In mice genetically engineered to lack AEP, both the drug and an artificial stroke resulted in reduced DNA damage and less brain cell death than in regular mice.

This outcome suggests that AEP might be the major proteinase mediating this devastating process, the authors wrote.

WHI follow-up study: Risks of long-term hormone therapy continue to outweigh benefits

Tue, 04 Mar 2008 05:00:00 PST

( from http://www.rxpgnews.com ) New results from the Women's Health Initiative (WHI) confirm that the health risks of long-term use of combination (estrogen plus progestin) hormone therapy in healthy, postmenopausal women persist even a few years after stopping the drugs and clearly outweigh the benefits. Researchers report that about three years after women stopped taking combination hormone therapy, many of the health effects of hormones such as increased risk of heart disease are diminished, but overall risks, including risks of stroke, blood clots, and cancer, remain high. The WHI is sponsored by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH).

Results of the WHI three-year follow-up study of the estrogen-plus-progestin clinical trial are published in the March 5, 2008, issue of the Journal of the American Medical Association.

The good news is that after women stop taking combination hormone therapy, their risk of heart disease appears to decrease, noted Elizabeth G. Nabel, M.D., NHLBI director. However, these findings also indicate that women who take estrogen plus progestin continue to be at increased risk of breast cancer, even years after stopping therapy. Today's report confirms the study's primary conclusion that combination hormone therapy should not be used to prevent disease in healthy, postmenopausal women.

The FDA recommends that hormone therapy never be used to prevent heart disease, and, when hormone therapy is used for menopausal symptoms, it should only be taken at the smallest dose and for the shortest time possible.

The new findings are from a follow-up study of 15,730 postmenopausal women with an intact uterus, ages 50 to 79 years (average age of 63) at enrollment, who participated in the WHI estrogen-plus-progestin clinical trial. Participants were randomly assigned to receive a combination of estrogen (0.625 milligrams of conjugated equine estrogens per day) plus progestin (2.5 mg of medroxyprogesterone acetate) or placebo (inactive pill). The main estrogen-plus-progestin study was stopped in 2002 after an average of 5.6 years of treatment due to an increase in breast cancer. Women on combination hormone therapy were also at increased risk of stroke, blood clots, and heart disease, while their risk of colorectal cancer and hip fractures was lower, compared to women who did not take hormone therapy.

The follow-up study began in July 2002 after women in the study were instructed to stop taking combination hormone therapy, and continued through March 2005, with participants followed for an average of 2.4 years. All study participants were examined at least once a year by a WHI clinician and received an annual breast examination and mammogram, with biopsies performed as needed. During the follow-up study, the numbers of heart attacks, strokes, and blood clots were not significantly different between the two groups (overall, 343 cardiovascular events among those who initially received hormone therapy versus 323 among those who did not). In addition, the number of deaths was not significantly different (233 women who had been in the hormone therapy group died, versus 196 women who had been in the placebo group).

Reduction of stroke risk with aerobic fitness

Fri, 22 Feb 2008 06:27:29 PST

( from http://www.rxpgnews.com ) A moderate level of aerobic fitness can significantly reduce stroke risk for men and women, according to a large, long-running study presented at the American Stroke Association’s International Stroke Conference 2008.

“Fitness has a protective effect regardless of the presence or absence of other stroke risk factors, including family history of cardiovascular disease, diabetes, high blood pressure, elevated cholesterol levels and high body mass index,” said Steven Hooker, Ph.D., the study’s lead author.

“This study is the first to suggest that there may be a significant independent association between cardiorespiratory fitness (CRF) and fatal and nonfatal stroke in men and nonfatal stroke in women,” said Hooker, director of the Prevention Research Center at the University of South Carolina Arnold School of Public Health, Columbia, S.C.

About 780,000 U.S. adults suffer a stroke each year, and stroke is a leading cause of serious, long-term disability in the United States, according to the American Stroke Association. It’s often fatal, claiming about 150,000 lives and ranking as the No. 3 cause of death. Researchers analyzed data on more than 60,000 people — 46,405 men and 15,282 women who participated in the Aerobics Center Longitudinal Study between 1970 and 2001 at the Cooper Aerobics Center in Dallas. The participants, ages 18 to 100 and free of known cardiovascular disease when they entered the study, were followed for an average of 18 years. During that time, 863 people — 692 men and 171 women — had strokes.

Upon entering the study, each participant took a test to measure CRF in which they walked on a treadmill at increasing grade and/or speed until they reached their maximal aerobic capacity.

Although many previous studies have looked at an association between self-reported physical activities and cardiovascular disease, few have used direct measurements such as the CRF measure used in this study, Hooker said. This is also the first study to explore the association between CRF and risk of stroke in women.

Men in the top quartile (25 percent) of CRF level had a 40 percent lower relative risk of stroke compared to men in the lowest quartile. That inverse relationship remained after adjusting for other factors such as smoking, alcohol intake, family history of cardiovascular disease, body mass index (an estimation of body fatness), high blood pressure, diabetes and high cholesterol levels, he said.

Among women, those in the higher CRF level had a 43 percent lower relative risk than those in the lowest fitness level.

The overall stroke risk dropped substantially at the moderate CRF level, with the protective effect persisting nearly unchanged through higher fitness levels. That corresponds to 30 minutes or more of brisk walking, or an equivalent aerobic activity, five days a week.

“We found that a low-to-moderate amount of aerobic fitness for men and women across the whole adult age spectrum would be enough to substantially reduce stroke risk,” Hooker said.

“Although stroke death rates have declined over the past few decades, the public health burden of stroke-related disabilities continues to be large and may even increase in coming years, as the population ages.”

Physical activity is a major modifiable cardiovascular disease risk factor. Increasing the nation’s CRF through regular physical activity could be a vital weapon to lower the incidence of stroke in men and women, he said.

One of the study’s limitations is that most of the participants were white, well-educated and middle-upper income, he said. He recommended that data be collected from other populations.

Research shows a daily dose of beetroot juice can beat high blood pressure

Wed, 06 Feb 2008 05:40:00 PST

( from http://www.rxpgnews.com ) Researchers at Barts and The London School of Medicine have discovered that drinking just 500ml of beetroot juice a day can significantly reduce blood pressure. The study, published online today in the American Heart Association journal Hypertension, could have major implications for the treatment of cardiovascular disease.

Lead by Professor Amrita Ahluwalia of the William Harvey Research Institute at Barts and The London School of Medicine, and Professor Ben Benjamin of Peninsula Medical School, the research reveals that it is the ingestion of dietary nitrate contained within beetroot juice - and similarly in green, leafy vegetables - which results ultimately in decreased blood pressure. Previously the protective effects of vegetable-rich diets had been attributed to their antioxidant vitamin content.

Professor Ahluwalia and her team found that in healthy volunteers blood pressure was reduced within just 1 hour of ingesting beetroot juice, with a peak drop occurring 3-4 hours after ingestion. Some degree of reduction continued to be observed until up to 24 hours after ingestion. Researchers showed that the decrease in blood pressure was due to the chemical formation of nitrite from the dietary nitrate in the juice. The nitrate in the juice is converted in saliva, by bacteria on the tongue, into nitrite. This nitrite-containing saliva is swallowed, and in the acidic environment of the stomach is either converted into nitric oxide or re-enters the circulation as nitrite. The peak time of reduction in blood pressure correlated with the appearance and peak levels of nitrite in the circulation, an effect that was absent in a second group of volunteers who refrained from swallowing their saliva during, and for 3 hours following, beetroot ingestion.

Weill Cornell team discovers how brain's own tPA helps regulate blood flow to neurons

Thu, 17 Jan 2008 05:00:00 PST

( from http://www.rxpgnews.com ) NEW YORK (Jan. 17, 2008) -- The human brain contains its own store of a powerful enzyme (and stroke drug) called tissue plasminogen activator (tPA), which appears to be a key regulator of blood flow to brain cells, a team at the Weill Cornell Medical College in New York City reports.

We found that this natural tPA boosts blood flow to brain cells via its influence on nitric oxide synthase, which is essential to the production of nitric oxide (NO). NO is a well-known vasodilator -- a drug or chemical that widens blood vessels -- so, more NO means better blood flow to neurons as they become more active, explains study senior author Dr. Costantino Iadecola, the George C. Cotzias Distinguished Professor of Neurology and Neuroscience at Weill Cornell Medical College, and chief of the Division of Neurobiology at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

The findings have just been published in this week's online issue of Proceedings of the National Academies of Science.

Besides elucidating the role of naturally produced tPA in neuronal blood flow, the new findings could have implications for the study of stroke and Alzheimer's disease. Both conditions are associated with marked declines in natural brain levels of tPA.

TPA has become a star of sorts in cardiovascular research over the past two decades, ever since scientists discovered its remarkable ability to break up clots.

Essentially, tPA, a powerful protease enzyme, cleaves a protein called plasminogen into plasmin, an enzyme that quickly 'eats up' clots, notes study lead author Dr. Laibaik Park, instructor in neuroscience at Weill Cornell. For that reason, doctors often administer a shot of tPA to stroke patients within minutes or hours of an attack.

But other research had also detected tPA occurring naturally in the human brain, with levels of the enzyme rising as brain cell activity increased.

What really piqued our interest was the finding from recent studies that tPA somehow modulates the activity of a protein lying on the surface of neurons called the NMDA receptor, Dr. Iadecola explains. This receptor serves as a gateway of communication between adjoining neurons, with glutamate being the 'currency' of exchange. Fluctuating levels of tPA seemed to influence just how much of that currency got through as brain cells became more or less active.

Exploring this mechanism further, Dr. Iadecola's team utilized a genetically engineered knockout mouse that lacked neuronal tPA. They tweaked the mouse's whiskers and watched blood flow in the area of the rodent's brain linked to whisker sensitivity.

In the knockout mouse, blood flow in that area did not change as much upon whisker stimulation -- confirming that tPA is necessary to boosting local blood flow, Dr. Iadecola says.

But how was tPA working, exactly? The prevailing theory -- that the enzyme impacted directly on the NMDA receptor -- was quickly proven wrong. We found that tPA was not acting as any kind of direct 'choke' on the NMDA receptor to allow more or less glutamate into the cell, says Eduardo Gallo, a graduate student in the Department of Neurology and Neuroscience, who played a key role in the study.

So, the team looked elsewhere at other rate-limiting mechanisms that might explain tPA's effects.

One of the end-products of NMDA receptor activity is nitric oxide (NO), a powerful vasodilator, Gallo notes. In our experiments, we discovered that tPA helps control how much NO can be made by activation of the NMDA receptor. TPA does so by boosting the ability of neuronal nitric oxide synthase (nNOS) -- an enzyme -- to produce NO. More tPA means more active nitric oxide synthase -- and more of this enzyme means more vessel-widening NO. The end result: a localized boost in blood flow to brain cells.

Questions remain, however. TPA exists outside the brain cell, but the nNOS activity and NO production goes on inside the neuron, Dr. Iadecola points out. That means there's some kind of biochemical chain connecting external tPA to these internal mechanisms, he says. Identifying the key players in that pathway will be a key part of our research going forward.

The new discoveries will have exciting implications for brain research, he says.

More and more, we are realizing that alterations in the availability of blood to brain cells is crucial to stroke and post-stroke recovery, and in the debilitating loss of neuronal function that underlies Alzheimer's disease and other dementias, Dr. Iadecola says.

It is possible that drugs or other interventions that manipulate the brain's natural supply of tPA could help preserve neurological function after stroke or Alzheimer's, or even help reverse some of the damage, he says. Those types of treatments are still a long way off, but our new understanding how tPA works to keep neurons healthy and active is a crucial first step in that research.

Carotid artery stenting- questions still remain

Wed, 16 Jan 2008 13:34:52 PST

( from http://www.rxpgnews.com ) A procedure called carotid artery stenting (CAS) has emerged as a minimally invasive alternative to surgery, called carotid endarterectomy (CEA), for patients with dangerous narrowing of the arteries supplying blood to the brain. However, questions remain about the best uses of this procedure—especially whether it is an appropriate alternative to surgery for "low-risk" patients, according to a special article in the January/February issue of Annals of Vascular Surgery.

"Currently, the choice of CEA versus CAS in individual patients is based more on individual practitioner experience than on clear evidence-derived guidelines," according to the new article by Drs. Philip P. Goodney and Richard J. Powell of Dartmouth-Hitchcock Medical Center, Lebanon, N.H. "Nonetheless, the popularity of less-invasive therapy combined with marketing of new CAS systems has increased the utilization of CAS."

Drs. Goodney and Powell review and summarize the research evidence on CAS to prevent stroke in patients with narrowing (stenosis) of the carotid arteries. In the CAS procedure, an expandable mesh device called a stent is placed to increase blood flow through the area of stenosis.

Recently, several randomized controlled trials—the strongest category of scientific evidence—have directly compared the results of CAS and CEA. It has now been fairly well established that CAS and CEA yield comparable results in "high-risk" patients.

However, debate continues as to the role of CAS in the much larger group of "low-risk" patients. Some studies suggest that CAS and CEA produce similar results, but others have found a lower rate of serious complications and death in patients undergoing surgery.

Drs. Goodney and Powell note several limitations of the research that make it difficult to compare results between trials. Studies being conducted now will help to clarify the relative performance of the two techniques in both high-risk and low-risk patients. A key question will be whether CAS or CEA is the better choice for patients considered high-risk because of medical conditions.

Other issues that will need to be worked through include refinements in the design of CAS systems and the role of detailed imaging studies in guiding treatment decisions. "Ongoing randomized trials will help determine optimal revascularization strategies in the future," the authors conclude.

Robotics lab helps stroke patients with recovery

Tue, 04 Dec 2007 05:00:00 PST

( from http://www.rxpgnews.com ) HOUSTON, Dec. 4, 2007 -- Robotics engineers at Rice University are teaming with doctors from Memorial Hermann|TIRR to develop a PC-based system for physical rehabilitation.

It can take months of physical therapy for stroke patients to regain the use of their limbs, said system architect Marcia O'Malley, director of Rice's Mechatronics and Haptic Interfaces Laboratory (MAHI). We hope to refine our system to allow patients to recover faster and to allow therapists to more precisely monitor patients' recovery.

O'Malley and Memorial Hermann|TIRR doctors this fall began a two-year study of a prototype rehabilitation system developed at MAHI that uses a joystick to help patients with eye-to-hand coordination. The study involved 16 patients. In one exercise, the patients use the joystick to move an object from one part of the computer screen to another. Like all the systems in O'Malley's lab, the rehab program uses force-feedback technology called haptics that allow people to feel their environment while they are in virtual reality.

The term haptic refers to the perception of touch, and in the prototype rehab system, the joystick is outfitted with motors that push the stick to resist moves in the wrong direction. As a result, the patient's hands are guided along the right path. By repeating the exercise over and over, patients can gradually learn to control the objects on the screen in a smooth, precise way.

We're interested in measuring how smooth the movements are, compared to what might be optimal, said O'Malley, assistant professor of mechanical engineering and materials science. The computer can precisely measure how a patient responds to every single exercise. This lets the doctors and physical therapists know exactly what their patient most needs to work on. This precise, measurable feedback provides a great advantage over the subjective evaluations currently in use.

O'Malley said researchers have been using computer-controlled robots for physical rehabilitation since the early 1990s, but so far the technology has been too expensive to use on a large scale. She thinks this will change within the next few years.

O'Malley said patients' enthusiasm for the technology is one reason it's likely to catch on.

The patients who get a chance to try this tend to get very excited, said O'Malley, who has previously worked with doctors and patients from the Department of Veterans Affairs. I've been inspired to see how hard patients are willing to work to regain their mobility, and our technology really plays to that strength. The machine never gets tired. It allows them to work as long and as hard as they want.

Women aren't men

Mon, 19 Nov 2007 05:00:00 PST

( from http://www.rxpgnews.com ) CHICAGO --- Women's bodies and medical needs are vastly different than men's way beyond their reproductive systems. Women wake sooner from anesthesia, have less familiar symptoms of cardiovascular disease and are more likely to suffer from depression and sleep problems-- just to name a few of the differences.

Yet, there's a cavernous void in research based on sex and gender. Historically, most studies have been done on men and the findings applied to women.

Northwestern University's Feinberg School of Medicine has launched the Institute for Women's Health Research to spur much needed research on health issues that affect women throughout their lifespan. Some topics on the ambitious research agenda: cancer, autoimmune disease, anesthesia, cardiovascular disease, depression, sleeping disorders, osteoporosis, osteoarthritis and menopause.

Another mission of the institute will be to create an Illinois Women's Health Registry to provide a large pool of potential study subjects for researchers, who often have trouble recruiting enough participants for their studies. Scientists at the institute also will identify gender-based guidelines for the treatment and prevention of disease in women. For example, do women need a differently designed knee joint than men in replacement surgery or do women need to be given anesthesia differently The institute will link physicians to these guidelines as they are developed.

We should look at every research study with a sex and gender lens and see what applies to women as opposed to men, said Teresa Woodruff, executive director of the new Institute for Women's Health Research and the Thomas J. Watkins Professor of Obstetrics and Gynecology at the Feinberg School. What are the differences between women and men that need further exploration What does gender mean in development of disease throughout the lifespan What is the influence of hormones We have many questions, but we don't have concrete answers.

Our goal is to deepen the medical and research community's understanding of women's health, Woodruff added. The knowledge we gain through fundamental research will be translated into improved sex and gender-specific clinical care.

Vivian Pinn, M.D., director of the Office of Research on Women's Health for the National Institutes of Health, came to Chicago to speak at the recent inauguration of the Institute for Women's Health Research.

It's rare to see this kind of commitment to research in women's health. I can count the institutions on my fingers, Pinn said. The issues Northwestern is working on will hopefully unlock the answers for many of these health issues. The results will have implications for the health of women worldwide. To improve women's health care, it's important to generate new knowledge.

To produce that knowledge, Woodruff is reaching out to researchers at the university and its clinical affiliates with grants to encourage them to incorporate gender differences into their studies. We are trying to instill the premise that biological sex matters in everybody's thought processes, she said, noting many scientists have never considered gender in their research.

One such physician was Melina Kibbe, M.D., assistant professor of surgery at the Feinberg School and a vascular surgeon at Northwestern Memorial Hospital and the Jesse Brown VA Medical Center. Kibbe researches how to extend the effectiveness of such vascular procedures as balloon angioplasty and stenting, bypass grafting and other vascular procedures with limited durability.

Kibbe wasn't doing any gender-based research until Woodruff met with her a few months ago and asked if she would include a cohort of women in her research. Thus, Kibbe began a new study with funding from the new institute to see whether her therapy -- which extends the effectiveness of the vascular procedures with nitric oxide-- produced different results in male and female animals. To her surprise, preliminary findings showed it did.

Kibbe's early results reveal male animals respond better to the nitric-oxide-based therapy better than females. If we actually see gender differences in our therapy when the study is complete, it may mean that we have to tailor our therapy so that it could be equally effective in both genders, she said. This could lead me down a whole new research path.

In cardiovascular therapies, gender research is in its infancy, Kibbe noted. Right now very few investigators are looking at the differences between men and women with respect to these cardiovascular therapies, she said.

A common obstacle for most researchers is recruiting enough participants for their studies. To address this challenge, the institute will develop the Illinois Women's Health Registry to provide a vast pool of potential study subjects with diverse backgrounds. This registry will be a critical tool for researchers who don't necessarily have the staff or the marketing skills to go out and recruit people.

The registry will tap the 12,000 women who come through Prentice Women's Hospital each year as well as the community at large, so all women will have an opportunity to participate. Woodruff hopes this registry will encourage researchers to do more gender studies.

One reason researchers have shied away from using women in studies is their fluctuating hormones. Hormones are complex, but they can be taught, Woodruff said.

2 carotid artery stenting studies show results comparable to AHA guidelines

Tue, 23 Oct 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Washington D.C., October 23, 2007 - Two carotid stenting trials examining patient outcomes demonstrated results that are comparable to guidelines established by the American Heart Association (AHA) for patients treated with carotid artery surgery. The results of these studies were presented today at the Cardiovascular Research Foundation's 19th annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium by William A. Gray, M.D., FACC, associate professor of clinical medicine at Columbia University College of Physicians and Surgeons and director of Endovascular Services at the Center for Interventional Vascular Therapy at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York. Dr. Gray is the director of Endovascular Services at the Cardiovascular Research Foundation.

An interim analysis of patients treated with carotid stents in Abbott�s CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) and EXACT (Emboshield and Xact Post Approval Carotid Stent Trial) post-marketing trials, which enrolled 4,111 patients in over 150 sites, demonstrated 30 day patient outcome results consistent with longstanding AHA guidelines for patients with a severe carotid stenosis but who do not have symptoms. These guidelines recommend that rates of complications for carotid artery surgery to prevent stroke be less than 3 percent for patients without symptoms of stroke (asymptomatic) and 6 percent for patients with symptoms of stroke (symptomatic).

�In these two well-conducted carotid artery stenting studies, carotid stenting has achieved outcomes comparable guidelines established for patients who undergo carotid surgery, and has done so in a population of patients who are at high risk for experiencing adverse events from surgery,� said Dr. Gray. �This is a significant report because this is the first time that these guidelines have been achieved by any revascularization therapy in a large, multi-center examination of such patients, and although the guidelines were established for surgery (before stenting was practiced), there are no comparable surgical results in this group of patients.�

In 1998, the American Heart Association published its 30 day outcome guidelines in Circulation for patients treated with carotid artery surgery. These guidelines were based on the observed stroke and death rates in patients with carotid artery disease who had undergone surgery, called carotid endarterectomy, to treat their condition. The guidelines were based on studies of surgery in patients who did not have excessive risks for anesthesia, etc., but left unanswered what the best therapy is for patients for whom surgery was risky. These two studies are the first demonstration of a therapy providing stroke prevention (carotid artery stenting) in these patients and they provide an option to those facing difficult decisions regarding the risks of surgery.

The CAPTURE 2 study included 1,987 patients and utilized Abbott's ACCULINK(tm) Carotid Stent System and ACCUNET(tm) Embolic Protection System. The EXACT study included 2,124 patients and utilized Abbott's Xact(r) Rapid Exchange Carotid Stent System and Emboshield BareWire(tm) Rapid Exchange Embolic Protection System. The key objective of both trials was to determine whether carotid stenting could be performedsafely in the real-world clinical setting by physicians with varying levels of experience. The primary endpoints were death, stroke and MI at 30 days. The demographics of patients in both trials were similar.

The 30-day composite endpoints of stroke and death for patients in the CAPTURE 2 and EXACT studies were:

Study explains how exercise lowers cardiovascular risk

Mon, 22 Oct 2007 04:00:00 PST

( from http://www.rxpgnews.com ) DALLAS, Oct. 23 �� It��s well known that physical activity can improve cardiovascular health. But it��s the impact exercise has on specific known risk factors that accounts for about 60 percent of that improvement, researchers reported in Circulation: Journal of the American Heart Association.

In a major study of over 27,000 women in the Women��s Health Study, researchers assessed a variety of risk factors and different levels of exercise in women who were followed for 11 years for new diagnosis of heart attack and stroke.

��Regular physical activity is enormously beneficial in preventing heart attack and stroke,�� said Samia Mora, M.D., lead author of the study and instructor of medicine at Harvard Medical School in the divisions of preventive and cardiovascular medicine at Brigham and Women��s Hospital, Boston Mass. ��We found that even modest changes in risk factors for heart disease and stroke, especially those related to inflammation/hemostasis and blood pressure, can have a profound impact on preventing clinical events. This study is the first to examine the importance of a variety of known risk factors in explaining how physical activity prevents heart disease and stroke.��

The women ranged from 45 to 90 years old (average age 55) and were assessed for a full range of risk factors and different levels of exercise. There was a 40 percent reduction in heart attack and stroke between the highest and lowest exercise groups. The women self-reported physical activity, weight, height, hypertension and diabetes.

The long-term benefits of exercise start at a relatively low level, 600 kilocalories per week, equivalent to about two hours of physical activity per week, Mora said.

The study measured levels of a variety of traditional and novel risk factors to help understand the mechanisms that reduce risk for heart attack and stroke. Novel risk factors are emerging clinical, biochemical, and genetic markers that researchers have studied in order to better understand the development of a disease, to improve disease risk prediction, and to identify new targets for treatment.

Inflammatory and hemostatic biomarkers �� fibrinogen, C-reactive protein and intracellular adhesion molecule-1 �� together made the largest contribution to lower risk, 33 percent.

Blood pressure was the next major contributor to lower risk, 27 percent, followed by lipids, body mass index, glucose abnormalities, with minimal contribution from measures of renal function or homocysteine.

Inflammatory and hemostatic biomarkers are novel risk factors that relate to blood vessel function and inflammation of the arteries.

��Inflammatory and hemostatic factors as a group have overlapping functions and roles and, in our study, had the biggest effect in mediating exercise-related cardioprotection, more so than blood pressure or body weight,�� Mora said.The study population was divided into four groups by levels of exercise:

Horizons AMI trial data to be presented at TCT 2007

Mon, 15 Oct 2007 04:00:00 PST

( from http://www.rxpgnews.com ) WASHINGTON, DC � OCTOBER 15, 2007 -- The Cardiovascular Research Foundation (CRF) will release results of its landmark research study, HORIZONS AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) at the nineteenth annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium in Washington, D.C. The study is designed to examine the safety and effectiveness of stents and anticoagulants in heart attack patients undergoing angioplasty.

The HORIZONS AMI trial data will be presented at a press conference on Wednesday, October 24 at 8:40 am. The results will be presented as a late breaking trial on Wednesday, October 24 at 10:50 am.

�This is a landmark trial, which will help set guidelines for drug and stent therapy during primary angioplasty in patients with heart attacks for many years to come,� said Gregg W. Stone, MD, Chairman of the Cardiovascular Research Foundation and Professor of Medicine, Columbia University Medical Center.

While previous studies of drug-eluting stents have often focused on their use in patients with stable or unstable chest pain, this is the largest study to focus on the appropriate use of anticoagulation medications and drug-eluting stents in patients experiencing the highest risk form of heart attack (ST-elevation myocardial infarction).

�Usually, angioplasty is associated with an excess of bleeding in heart attack patients,� Dr. Stone said. �However, using the anticoagulant bivalirudin with angioplasty in patients with stable coronary artery disease instead of heparin and glycoprotein IIb/IIIa inhibitors reduces bleeding, which has been associated with greater long-term survival. In the HORIZONS AMI trial, we have sought to determine whether using bivalirudin in patients with a heart attack, who undergo angioplasty, provides the same benefit.�

�This study should determine if bivalirudin use is as efficacious as the standard anticoagulant therapy, without causing excess bleeding in these acutely ill patients with a heart attack undergoing angioplasty,� Dr. Mehran, Medical Director of the Data Coordinating and Analysis Center at CRF stated. She and her team conducted this study under an Investigational Device Exemption (IDE) from the Food and Drug Administration.

The HORIZONS AMI trial enrolled over 3600 patients presenting to hospitals in 11 countries with a heart attack. More than 120 national and international interventional cardiology centers are participating in the trial. Patients undergoing angioplasty were randomly assigned to receive either the standard anticoagulant unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor or bivalirudin alone. The patients are to be followed for five years.

Thirty-day outcome data will be presented, the primary endpoint of the study.

Comparison of Drug-Eluting Stents to Bare-Metal Stents UnderwayPatients enrolled in the HORIZONS AMI trial were also randomly assigned to receive either Taxus drug-eluting stents or a bare-metal stent. Data on this portion of the study � also a landmark comparison of drug-eluting stents to bare-metal stents � will be available next year.

Chronic job strain doubles the risk of a second heart attack

Tue, 09 Oct 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Quebec City, October 9, 2007�People who experience chronic job strain after a first heart attack double their risk of suffering from a second one, reports a research team from Universit� Laval�s Faculty of Medicine in the October 10 issue of the Journal of the American Medical Association.

This study is the first to clearly demonstrate the risks associated with job strain for workers who have been victim of a first heart attack. Research had previously shown a relationship between work-related stress and a first coronary heart disease (CHD) event, but studies examining job strain and recurrent CHD were few, limited in scope, and inconsistent in their findings.

The research team supervised by Chantal Brisson followed a group of 972 participants, ages 35 to 59, who had suffered a heart attack. These people were interviewed six weeks, two years, and then six years after returning to work in order to collect data on their health, lifestyles, sociodemographic status, and levels of work stress A job was defined as stressful if it combined high psychological demands (heavy workload, intense intellectual activity, and important time constraints) and little control over decision-making (lack of autonomy, creativity, and opportunities to use or develop skills).

During the six-year follow-up period, 124 participants suffered a second heart attack and 82 experienced unstable angina for a total of 206 recurrent CHD events. People who had reported high levels of stress at work during the first two interviews were twice as likely to fall victim to another CHD event. The risk remained the same even after taking into account factors such as severity of the first heart attack, other health conditions, family history, lifestyle, sociodemographic status, personality, and other work-environment characteristics.

The study shows that during the first two years following a heart attack, job strain does not increase the probability of experiencing a second CHD event. �It make sense on a biomedical level, since the pathological process at the source of the CHD requires some time before it can manifest itself,� comments Brisson.

Researchers insist on the importance of disseminating the results of this study in the workplace, so as to protect people from potentially harmful situations when they return to their jobs after a heart attack. �Employers and occupational health service professionals must find ways to modify the psychological demands of a job or the level of control over decision-making for people returning to work after a heart attack,� suggests Brisson. �It can be done, and encouraging autonomy, creativity, and the development of professional abilities in the workplace is not incompatible with a company�s productivity,� concludes the researcher.

Treating obstructive sleep apnea, preventing heart attacks and strokes

Fri, 28 Sep 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Researchers in Brazil have found that treating patients who suffer from obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) dramatically reduces early indications of atherosclerosis in just months, linking OSA directly to the hardening or narrowing of the arteries. Until now, no study has demonstrated such a direct relationship between the two.

�OSA is independently associated with increased risk of fatal cardiovascular events that can be reversed by treatment with CPAP,� wrote Luciano Drager, M.D., of the University of S�o Paulo Medical School in Brazil.

The research was published in the first issue of the American Journal of Respiratory and Critical Care Medicine for October of 2007, published by the American Thoracic Society.

The researchers selected 24 men with severe OSA and no other comorbidities and randomly assigned them to receive either CPAP therapy or no treatment. After establishing the baseline data for each subject, they then tracked several indicators of pre-clinical atherosclerosis, including carotid intima-media thickness (a measure of arterial plaque), pulse-wave velocity (a measure of arterial stiffness), carotid diameter, C-reactive protein (a marker of inflammation), and catecholamine level (a marker of physical stress) over the course of four months.

�[All markers] were similar across the study period in the control group,� wrote Dr. Drager. �In contrast, the group treated with CPAP had a significant decrease in carotid intima-media thickness, pulse-wave velocity, C-reactive protein, and catecholamines.�

While there is a known association between OSA and risk of myocardial infarctions and strokes, the causal connection between OSA and atherosclerosis as the principle mechanism behind those cardiovascular events has proven difficult to establish.

�The majority of patients with OSA share several risk factors for atherosclerosis, including obesity, hypertension, hypercholesterolemia, insulin resistance, and hyperglycemia,� explained T. Douglas Bradley, M.D., and Dai Yumino, M.D., both of the Sleep Research Laboratory at the Toronto Rehabilitation Institute at the Centre for Sleep Medicine and Circadian Biology at the University of Toronto, in an editorial in the same issue of the journal.

Furthermore, while non-randomized observational trials have suggested that the risk of adverse cardiovascular events is lower among patients who accept treatment by CPAP than in patients who do not accept CPAP therapy, it is possible that this difference may be due to better overall adherence to all prescribed treatments in patients who accept CPAP than in those who do not, as opposed to any direct benefit of CPAP itself.

�Whereas physiological studies suggest that OSA provides a substrate for the development of atherosclerosis, and epidemiological and observational studies suggest an association between OSA and odds of having atherosclerosis, there remains a gap between cause and effect yet to be filled,� wrote Drs. Yumino and Bradley. �Drager and colleagues provide evidence that begins to fill that gap.�

Indeed, after four months of CPAP therapy, carotid intima-media thickness declined by nine percent, which is remarkable in light of the fact that in a large-scale study, patients undergoing cholesterol-lowering pravastatin therapy saw carotid intima-media thickness decline by twelve percent after a full year. Other indicators showed similar magnitudes of improvement.

The researchers put forth a number of potential pathways whereby OSA could contribute to atherosclerosis progression, including inflammation, oxidative stress, lymphocyte activation, and high-density lipoprotein dysfunction. �CPAP treatment could reverse several of these pathways,� they wrote.

Still, the investigators caution that, while they are confident in the biological validity of their results, the rigid inclusion criteria makes it difficult to extrapolate their results to different populations, including women, patients with other co-morbidities and patients with mild to moderate OSA.

Possible safer target for anti-clotting drugs found

Wed, 26 Sep 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Researchers at the University of Illinois at Chicago College of Medicine have identified a new molecular target in blood clot formation, which seems to reduce clotting without excessive bleeding, the common side-effect of anti-clotting agents.

The findings are reported in the September issue of Molecular and Cellular Biology.

It was very surprising to find an enzyme whose inhibition lessened platelet aggregation without abnormal bleeding, and we immediately realized that it could have very important implications for the treatment of cardiovascular disease, said Shafi Kuchay, a graduate student in pharmacology and first author of the paper.

When clots form, small blood cells called platelets begin to clump together. Aspirin and other anti-clotting agents reduce the risk of heart attack and stroke by blocking the biochemical pathway that causes platelets to become sticky. But all these drugs put patients at risk of excessive bleeding.

The UIC researchers made a mouse model that lacked a gene for a protease enzyme most commonly found in blood cells called calpain-1, in order to determine its function. They found that mice lacking calpain-1 had reduced platelet aggregation but did not have any abnormal bleeding.

The mice lacking calpain-1 (called knockout mice) had increased levels of another enzyme, known as protein tyrosine phosphatase-1B. When the mice were given a PTP1B inhibitor, the reduced platelet aggregation was restored. When calpain-1 knockout mice and mice lacking PTP1B were crossed to create double-knockout mice, platelet aggregation was restored in the offspring that lacked the genes for both enzymes. The researchers were thus able to establish that PTP1B turns off the signal for platelet aggregation and that calpain-1 regulated the amount and activity of this off switch.

Because of the danger of excessive bleeding, people taking anti-clotting medications are monitored carefully and warned not to exceed their recommended doses, said Dr. Athar Chishti of the UIC Cancer Center, and senior author of the study. Our research unveils a new molecular target for anti-platelet drugs, which may avoid the dangerous side-effects of the current drugs.

In a secondary, serendipitous finding, the fact that the calpain-1 knockout mice have elevated PTP1B levels may prove important to research into diabetes and obesity.

Mice that lack the gene for PTP1B have been known for some time to display increased insulin sensitivity and resistance to diet-induced obesity, said Chishti, who is professor of pharmacology. He noted that PTP1B inhibition has already been identified as a therapeutic goal by many researchers in diabetes and obesity.

Our calpain-1 knockout mice with their elevated PTP1B levels offer a good model system for testing the potency of novel PTP1B inhibitors, he said.

Murder mystery solved

Thu, 20 Sep 2007 04:00:00 PST

( from http://www.rxpgnews.com ) CHICAGO --- It was a murder mystery playing out in major cities across the country and perplexing scientists. Thousands of people were dying from strokes and heart attacks within 24 hours of a spike in microscopic pollution -- tiny particles that spew from the exhaust of diesel trucks, buses and coal-burning factories.

But scientists didn't have a smoking gun. They couldn't figure out why the pollution was triggering the deaths. All they had to go on was a vague lead: the particles -- too small to be filtered by the nose or mouth -- caused inflammation of the lungs. But what was the link between particles trapped in the lungs to the strokes and heart attacks

New research from the gumshoes at Northwestern University�s Feinberg School of Medicine has solved a key piece of the mystery. The study identifies how these tiny pieces of soot -- called particulate matter air pollution -- kill people at risk and tells how they can protect themselves from these pollution-related strokes and heart attacks.

Northwestern researchers have discovered that this microscopic air pollution � smaller than 10 microns or less than one-tenth of the diameter of a human hair -- spurs hyperclotting of the blood. The study found that lungs inflamed by the pollution secrete a substance, interleukin-6, which causes an increased tendency for blood to coagulate or clot. This raises the risk of a fatal heart attack or stroke in people with cardiovascular disease such as coronary artery disease, congestive heart failure or a history of stroke.

Previous epidemiological research has linked the pollution to cardiovascular death and disease, but this is the first study to show how it actually happens in an animal model.

This is a critical missing piece of the puzzle that has eluded scientists for decades, said Gokhan Mutlu, M.D., lead author of the study and assistant professor of pulmonary and critical care medicine at the Feinberg School, and a physician at Northwestern Memorial Hospital. Now we know how the inflammation in the lungs caused by air pollutants leads to death from cardiovascular disease.

People at risk can probably help protect themselves by taking low-dose aspirin to keep their blood thin, Mutlu said.

Mutlu collaborated on the study with co-authors Scott Budinger, M.D. associate professor of pulmonary and critical care medicine, and David Green, M.D., professor of hematology and oncology, both at the Feinberg School and physicians at Northwestern Memorial Hospital.

The paper will appear on-line Sept. 20 in the Journal of Clinical Investigation and will be published in the print issue October 1.

In the study, researchers used particles of pollution collected by the United States Environmental Protection Agency, mixed them into a saline solution and injected the pollution cocktail into the lungs of mice. The blood of the mice exposed to the pollution clotted faster than mice not exposed. Researchers observed a 15-fold increase in interleukin-6 24 hours after the mice were exposed to the pollution.

In people, interleukin-6 also raises the levels of a substance called CRP, which is correlated with death from cardiovascular disease.

Particulate matter pollution is highest near expressways or truck routes. It's hard for commuters to escape. People are exposed to the pollution inside a car (even with the windows rolled up), a train or walking outdoors, Mutlu said. The only safe location with lower levels is indoors.

People with previous blockages in the coronary or carotid arteries are at the highest risk. It's important to get screened to see if you have one of these conditions. If so, when there are high levels of particulate matter, you should try to stay indoors and limit your exposure to the outside air, Budinger said.

Exercising hikes the risk because it floods the lungs with more polluted air. If you're sitting down, the amount of air you get into your lungs is about five to six liters per minute, but if you're running the amount is 20 to 25 liters, Mutlu noted. If you�re close to an expressway, you're actually breathing more particulate matter into your lungs.

The doctors also warned that heart attacks and strokes occur at relatively low levels of particulate matter pollution. We haven't found a safe level yet, Mutlu said. He hopes the study helps encourages the EPA and local regulators to reduce the limits on particulate matter levels.

The American Lung Association State of the Air: 2007 report said the most ominous trend in air pollution is the increase in particle pollution, particularly in the eastern United States. Among the metropolitan areas, Los Angeles has the most year-round particle pollution. Chicago ranks 11; New York, 17 and Washington D.C., 20. All received an F or failing grade for their pollution , which was in excess of the EPA annual average limit of 15 micrograms per cubic meter.

The risk of dying from a heart attack or ischemic stroke jumps a whopping 30 percent with each additional 10 micrograms of pollution.

While the current Northwestern study looked at the acute effects of this microscopic pollution, Mutlu also has begun to research its long-term exposure on cardiovascular health. He is piping air on the street from Huron and Lake Shore Drive in downtown Chicago into a chamber with mice. Over the next several years, he will examine the effect of breathing this air on the mice's cardiovascular health.

New research shows ACTOS is associated with a 38 percent lower risk of heart attack

Wed, 19 Sep 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Amsterdam, The Netherlands, Sept. 19, 2007 -- New research, including two studies presented this week at the 43rd Annual Meeting of the European Association for the Study of Diabetes (EASD), further support the cardiovascular safety of ACTOS (pioglitazone HCI) and its benefits regarding improved blood glucose and blood lipid levels for patients with type 2 diabetes. The unique outcomes, including some clinical practice results, reinforce the consistency of pioglitazone data and underscore that ACTOS has different effects from the other thiazolidinedione rosiglitazone due to differences in molecular structure.

New research [1] presented at EASD has shown that therapies which include pioglitazone are associated with significant reductions in the risk of stroke or myocardial infarction (MI) compared to non-thiazolidinedione therapies. This retrospective analysis of case records from a large managed care database of diabetes patients have shown that the adjusted relative risk of stroke for the pioglitazone group was 20 percent lower than the group not receiving pioglitazone. Likewise, the risk of heart attack over the study period was 38 percent lower in patients receiving pioglitazone than in those taking an anti-diabetes drug regimen that did not include pioglitazone. John Betteridge, Professor of Endocrinology and Metabolism at University College, London said: �The results of this analysis are very welcome and support the findings from the PROactive study of pioglitazone for secondary prevention of vascular events which showed a reduction in stroke and heart attack in this high risk population.�

In addition, the GLAI study [2] , also presented at EASD, further reflects the cardioprotective strength of pioglitazone. A new analysis of data from the first three months of this six-month head-to-head study of pioglitazone and rosiglitazone, in which the endpoint was the change in serum lipids, demonstrated that initial treatment with a starting dose of pioglitazone (30 mg) was more effective than a starting dose of rosiglitazone (4 mg) in improving blood glucose (HbA1c) levels and lipid levels. Also, researchers found that in addition to lowering HbA1c significantly more than rosiglitazone, pioglitazone also significantly decreased triglyceride levels and non-HDL cholesterol (a predictor of cardiovascular death), and markedly improved HDL-C levels (�good� cholesterol) versus rosiglitazone. �A likely explanation for the different effects on heart attack and strokes between the two drugs could be the favourable effect of pioglitazone in increasing HDL cholesterol without adverse effects on LDL as demonstrated in the GLAI study,� said Professor Betteridge.

The data presented at EASD add weight to a growing body of evidence including newly published findings from a large retrospective cohort trial published recently in the journal of Pharmacoepidemiology and Drug Safety [3] , which showed that pioglitazone is associated with a 22 percent relative risk reduction of hospitalization for acute myocardial infarction in patients with type 2 diabetes compared to rosiglitazone. In addition, they correlate with findings from a meta analysis published in the Journal of the American Medical Association [4] which demonstrated that pioglitazone reduces the risk of heart attack, stroke or death by 18 percent in patients with type 2 diabetes.

New therapy could preserve vessel function after heart attack

Mon, 10 Sep 2007 04:00:00 PST

( from http://www.rxpgnews.com ) COLUMBUS , Ohio � Scientists have identified the process that causes blood vessels to constrict during and after a heart attack. They've also demonstrated that delivering a vital molecule that is depleted during this process directly to those blood vessels can reverse damage and help restore blood flow.

The Ohio State University medical researchers say these findings have the potential to improve outcomes for patients with acute coronary episodes related to ischemia, and to ameliorate the restriction of blood supply to the heart.

The study is published online this week in the journal Proceedings of the National Academy of Sciences.

�This is a useful therapeutic approach and should be easy to translate,� said Jay L. Zweier, director of the Davis Heart and Lung Research Institute at Ohio State University Medical Center and senior author of the study. �This should enable improved treatment of patients with unstable coronary syndromes and heart attacks, allowing enhanced restoration of blood flow and preservation of heart muscle at risk.�

Scientists have known that following a heart attack blood vessels around the heart do not properly dilate and may constrict because of problems in the cells that line the vessel walls. But until now, they did not precisely understand why. Zweier and colleagues set out to determine the cascade of events that leads to the loss of vessel vasodilatory function and, in the process, identified a potential solution that would dilate and reopen vessels, improving blood flow.

In examining isolated hearts, the research team observed that in hearts subjected to a lack of blood flow, or the ischemia that occurs during a heart attack, the ability of the vessels to remain dilated is impaired because production of the nitric oxide molecule that dilates the vessel stops. This stoppage can be traced to depletion during ischemia of a molecule that is a critical cofactor required to activate the enzyme nitric oxide synthase (NOS), which produces the potent vasodilator nitric oxide. This critical cofactor is a molecule called tetrahydrobiopterin, or BH4.

In fact, the loss of BH4 during ischemia not only prevents production of nitric oxide and the dilation it causes, but actually causes the enzyme NOS to completely reverse course and instead produce an oxidant called superoxide that leads to constriction of the vessels.

Zweier noted that the longer that blood flow is stopped during a cardiac event, the more severe the loss of BH4 � meaning the chances of restoring blood flow are increasingly reduced. The study showed a marked loss of BH4 after 30 minutes without blood flow, and more than 90 percent depletion after 45 minutes.

�What wasn't known before was that as the time of ischemia progresses, the function of the enzyme is impaired and subsequent coronary flow is reduced. There is loss of enzyme function plus the switch from dilation to constriction,� said Zweier, also a professor of internal medicine. �Following a heart attack, vessels tend to constrict and mircovascular occlusion occurs, but what you need is a patent circulation with dilated vessels for restoration of coronary flow, or the muscle will die.�

Because depletion of BH4 during ischemia is irreversible, the heart and coronary vessels cannot generate their own repair � which has important consequences for efforts to restore blood flow. So the scientists also developed a way to package the molecule and deliver it directly to the vessels. They discovered that the treatment was effective in partially restoring the process that opens and dilates the vessels with improved coronary flow.

Zweier said that because this approach controls blood vessel function at the cellular level, BH4 infusion could be used not just for acute heart attack treatment, but also to help prevent new blockages of coronary arteries after procedures such as angioplasty or bypass surgery.

He said the depletion of BH4 likely results from the burst of free radicals associated with both ischemia and the shock of the reintroduction of flow. This work is part of Ohio State medical scientists' ongoing search for ways to control the reintroduction of oxygen and other nutrients to the heart following a heart attack or other conditions with compromised coronary flow in a way that will prevent any further damage to the cardiac muscle. The key is striking a delicate balance between reducing the burst of free radicals that accompanies the reintroduced blood, which can damage tissue, and the need for enough free radicals to generate a stress response that will improve heart function and healing.

Study finds blocking angiogenesis signaling from inside cell may lead to serious health problems

Thu, 23 Aug 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Angiogenesis inhibitors that block a tumor�s development of an independent blood supply have been touted as effective cancer fighters that result in fewer side effects than traditional chemotherapy. However, a new study by researchers at UCLA�s Jonsson Cancer Center showed that one method of blocking blood supply development could result in serious and potentially deadly side effects.

Several newly developed angiogenesis inhibitors work by blocking vascular endothelial growth factor (VEGF), an important signaling protein that spurs growth of new blood vessels. Avastin, an approved angiogenesis inhibitor for colon and lung cancers, inhibits angiogenesis by blocking VEGF signaling from outside of the cell. UCLA researchers wanted to know what happened when VEGF signaling was blocked from within endothelial cells, a mechanism used by some small molecule drugs currently being tested in late phase clinical trials.

The result was unexpected, and sobering. More than half of the mice in the study suffered heart attacks and fatal strokes, while those that remained alive developed serious systemic vascular illness, said Luisa Iruela-Arispe, a professor of molecular, cell and developmental biology and director of the Cancer Cell Biology program at UCLA�s Jonsson Cancer Center.

The study appears in Aug. 24, 2007 in the prestigious, peer-reviewed journal Cell.

�This was an extremely surprising result,� said Iruela-Arispe, past president of the North American Vascular Biology Organization and a national expert on angiogenesis. �I think this study is cause for some caution in the use of angiogenesis inhibitors in patients for very long periods of time and in particular for use of those inhibitors that block VEGF signaling from inside the cell.�

About 5 percent of patients taking Avastin develop blood clot-related side effects, Iruela-Arispe said. But because Avastin was approved only three years ago, it is unclear what side effects may occur when patients remain on the drug for many years, she said.

In the three-year study, Iruela-Arispe created mice that were missing VEGF in the endothelial cells, the cells that line the inside of blood vessels and form an interface between circulating blood and the vessel wall. Endothelial cells line the circulatory system from the heart to the smallest capillary and reduce friction of the flow of blood. Iruela-Arispe and her team didn�t expect to see much of an effect because the amount of VEGF made inside endothelial cells was miniscule compared to the levels of VEGF created outside the cells.

However, 55 percent of the mice in the study died by 25 weeks of age, the equivalent of age 30 in humans. The other mice that were followed into old age were very ill.

�Some side effects have already been identified in people taking angiogenesis inhibitors,� Iruela-Arispe said. �And they�ve been along the lines of what we�re seeing in the lab.�

Iruela-Arispe and her team were surprised that the higher levels of VEGF found outside the endothelial cells did not compensate for the absence of the very tiny amounts inside the cells. The miniscule amount of VEGF missing had �a tremendous biological significance,� she said.

�Clearly there is signaling from inside the cell that is different from signaling initiated outside the cell,� Iruela-Arispe said. �When there is no VEGF signaling inside the cell, the endothelial cells die. The intracellular part of the VEGF signaling loop is required for cell survival. This is the first demonstration that intracellular signaling is an important event.�

It had been unclear why some patients on angiogenesis inhibitors developed problems with blood clots. Iruela-Arispe said her study sheds light on one possible cause.

�There is enough smoke in the sky here to make me feel there may be a fire,� she said. �I believe the survival function of VEGF signaling is mediated from both outside and inside the cell. When we block it from the inside, the outside signaling cannot compensate. But when we block it from the outside, maybe the inside signaling can compensate. That would explain the lesser side effects found when using drugs such as Avastin, which block the extra cellular signaling.�

Iruela-Arispe believes angiogenesis inhibitors will continue to be effective weapons in the cancer arsenal. However, a more targeted approach to drug delivery should be explored. Avastin, as well as most angiogenesis inhibitors, are infused systemically now. If the drugs could be targeted more directly to the new vessels being formed by the tumor, they might not result in the side effects seen now.

Broad-based group of physicians calls for improvement in stroke treatment

Tue, 21 Aug 2007 04:00:00 PST

( from http://www.rxpgnews.com ) (August 21, 2007 -- WASHINGTON, DC) � A coalition of physicians representing a wide range of medical specialties has issued a call to action to improve the treatment of stroke. The group, which includes nationally recognized leaders in neurology, neuroradiology, neurosurgery, vascular surgery, and cardiology, was drawn together by the Society for Cardiovascular Angiography and Interventions (SCAI) to address one of the most pressing medical needs in this country�the rapid treatment of stroke using catheter-based techniques.

�The only way to minimize the damage from a stroke is to restore blood flow to the brain and do it absolutely as quickly as possible,� said Christopher J. White, M.D., chairman of cardiology at the Ochsner Clinic Foundation, New Orleans, and director of the Ochsner Heart and Vascular Institute. �There is a huge shortage of physicians trained in catheter-based treatments for stroke, and we need to do something about it.�

A plan for solving that physician shortage is published online today and in the September 2007 issue of SCAI�s official journal, Catheterization and Cardiovascular Interventions (CCI). The document is entitled, �Interventional Stroke Therapy: Current State of the Art and Needs Assessment.� Dr. White is editor-in-chief of CCI.

Each year nearly three-quarters of a million people suffer a stroke in the United States. Stroke is the leading cause of disability in this country, and is responsible for 1 in 16 deaths.

The use of clot-busting drugs is a well-established therapy for stroke. However, only about 20 percent of stroke patients are considered eligible for clot-busters and only about 2 percent of stroke patients are actually treated with these medications. In part, this may be due to the narrow timeframe during which clot-busters are safe and effective�within just 3 hours of the onset of stroke symptoms. Unfortunately, most patients arrive at the emergency room too late.

Catheter-based treatment, also known as endovascular stroke therapy, has been shown to be effective over a longer time period�6 to 8 hours after the onset of stroke symptoms. Using this approach, a slender tube, or catheter, is threaded from an artery in the groin into the aorta, then up through the carotid arteries in the neck and into the specific artery in the brain that is blocked by a blood clot. In some cases, clot-busting medications are injected directly into the clot in hopes that it will dissolve. More often, a retrieval device with a corkscrew-like tip is passed through the catheter into the clot. When the device is pulled back into the catheter, it brings the clot with it. A stent is also sometimes implanted to prop open the artery.

�Never before have we had the capability to manage this disease with such advanced techniques,� said L. Nelson Hopkins, M.D., professor and chairman of neurosurgery and a professor of radiology at the State University of New York, Buffalo. �We need to get that capability broadly disseminated so we can do a better job for stroke patients. Stroke is a disaster for patients, families, and society.�

The ranks of those performing catheter-based treatment of stroke are alarmingly thin. There are only 385 interventional neuroradiologists practicing in the United States, according to survey data. In 5 states, not a single physician is available to perform endovascular stroke therapy.

The new document calls for solving this critical shortage by tapping into a group already trained in using catheters to treat carotid artery disease and strokes that occur as a complication of carotid stent placement, a procedure known as neuro-rescue. By adapting and expanding neuro-rescue skills, interventional cardiologists, interventional radiologists, and vascular surgeons could markedly increase the number of physicians available 24 hours a day, 7 days a week, to treat stroke.

This broad-based physician group would bring not only experience in catheter-based techniques to the treatment of stroke, but also a history of rapid triage and treatment of patients with a life-threatening illness. Cardiologists, for example, currently set a target of 90 minutes for treatment of a blocked artery causing a heart attack. That same model could be applied to stroke therapy.

�It just makes sense,� Dr. Hopkins said. �Cardiologists have advanced catheter skills, they are accustomed to dealing with blocked arteries on an emergency basis, and they could form multidisciplinary stroke teams that could be activated very quickly when a patient came to the emergency room with a stroke.�

The authors of the new document see it as a call to action, and hope it will spark a broad-based movement to form stroke teams capable of providing interventional treatment of stroke 24 hours a day, 7 days a week in communities throughout the nation. According to Dr. White, the ultimate goal is to have a stroke treatment center in every community capable of catheter-based stroke intervention�essentially, to offer the same level of care for a �brain attack� as for a heart attack.

�By tapping into the physicians currently performing carotid stenting, we could more than double the number of people capable of performing catheter-based interventional treatment of stroke,� Dr. White said. �Once you�ve seen the need, it�s impossible to step back.�

New research discovers independent brain networks control human walking

Tue, 07 Aug 2007 04:00:00 PST

( from http://www.rxpgnews.com ) (Baltimore, MD) - In a study published in the August issue of Nature Neuroscience, researchers at the Kennedy Krieger Institute in Baltimore, Maryland found that there are separate adaptable networks controlling each leg and there are also separate networks controlling leg movements, e.g., forward or backward walking. These findings are contrary to the currently accepted theory that leg movements and adaptations are directed by a single control circuit in the brain. The ability to train the right and left legs independently opens the door to new therapeutic approaches for correcting walking abilities in patients with brain injury (e.g., stroke) and neurological disorders (e.g., cerebral palsy and multiple sclerosis).

Using a split-belt treadmill to separately control the legs, Kennedy Krieger researchers Dr. Amy Bastian and Julia Choi studied forty healthy adults and tracked each persons ability to learn various walking exercises. Utilizing specialized computer software and infrared tracking devices placed on key joints, researchers found subjects could store different walking patterns for forward versus backward walking simultaneously, with no interference between the two, revealing that separate brain systems control the two directions of walking. Surprisingly, people could also walk easily with one leg moving forward and the other backward, a pattern referred to as hybrid walking. Adaptation of hybrid walking, in which varying speeds were applied to legs walking in opposite directions, was found to interfere with subsequent normal forward and backward walking. The combined results demonstrate there are distinct brain modules responsible for right/forward, right/backward, left/forward and left/backward walking. Most significantly, these modules can be individually trained, which would be critical for rehabilitation focused on correcting walking asymmetries produced by brain damage.

The notion that we can leverage the brains adaptive capacity and effectively dial in the patterns of movement that we want patients to learn is incredibly exciting, said Dr. Amy Bastian, senior study author and Director of the Motion Analysis Laboratory at the Kennedy Krieger Institute. These findings significantly enhance our understanding of motor skills, effective therapeutic approaches and the true adaptive nature of the brain.

The walking adaptations studied here represent a form of short term learning from practicing on this unusual treadmill. Investigators set different speeds for each belt of the treadmill causing subjects to walk in an abnormal limping pattern. However, within 15 minutes subjects adapted and learned to walk smoothly with a normal pattern and rhythm, as verified by computer models. This indicates that the phenomenon of brain plasticity can occur in short intervals. When subjects returned to normal conditions (same speed for the two legs), this adaptation caused an after-effect that resulted in a limp that lasted for five-to-ten minutes as they unlearned the correction. Regardless of how hard subjects tried, they were unable to stop this after-effect, because walking patterns are controlled by automatic brain systems that recalibrate themselves according to current conditions.

As we understand more about the way the brain learns, relearns and adapts in relation to motor skills, physical therapy professionals have a vastly expanding toolbox from which to tailor therapeutic interventions, explains Gary Goldstein, MD, President and CEO of the Kennedy Krieger Institute. This study and other research from Kennedy Kriegers Motion Analysis Laboratory provide a glimpse into the rehabilitative potential made possible through the pairing of our talented researchers and cutting-edge technologies.

Past studies by Bastian and her colleagues have found that certain types of brain damage interfere with walking ability, while others do not. For example, individuals with damage to the cerebral hemispheres can adapt while those with damage to the cerebellum are rarely able to.

This body of work sheds light on the specificity of walking adaptations and demonstrates that patients with certain types of brain damage can store a new walking pattern in the short term. Based on these findings, Bastians goal is to learn how to make that pattern last for an extended period. Currently, Bastian is planning a study of stroke victims in order to test the long-term benefits of split-belt treadmill therapy. She is also studying children with more extreme forms of brain damage, including those that undergo a hemispherectomy, a neurosurgical procedure to treat seizures in which an entire half of the brain is removed. The initial findings are quite promising, showing that these children can adapt in the short term and improve their walking patterns. These and other similar studies are leading researchers down the path to more targeted, rational therapies for patients with brain injuries.

UCLA study links air pollution to clogged arteries

Wed, 25 Jul 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Got high cholesterol? You might want to stay away from air pollution.

Thats the message of a new UCLA study linking diesel exhaust to atherosclerosis, or hardening of the arteries, which significantly increases ones risk for heart attack and stroke. Published in the July 26 edition of the online journal Genome Biology, the findings are the first to explain how fine particles in air pollution conspire with artery-clogging fats to switch on the genes that cause blood vessel inflammation and lead to cardiovascular disease.

When you add one plus one, it normally totals two, said principal investigator Dr. André Nel, chief of nanomedicine at the David Geffen School of Medicine at UCLA and a researcher at UCLAs California NanoSystems Institute. But we found that adding diesel particles to cholesterol fats equals three. Their combination creates a dangerous synergy that wreaks cardiovascular havoc far beyond whats caused by the diesel or cholesterol alone.

The researchers set up a scenario to investigate the interaction between diesel exhaust particles and the fatty acids found in low-density lipoprotein (LDL) cholesterol the bad type of cholesterol that leads to artery blockage.

In particular, the team was interested in how oxidation cell and tissue damage resulting from exposure to molecules known as free radicals contributes to inflammation and artery disease. Free radicals enter the body through small particles present in polluted air and are also byproducts of normal processes, such as the metabolic conversion of food into energy.

Diesel particles are coated in chemicals containing free radicals, and the fatty acids in LDL cholesterol generate free radicals during metabolism in the cells, said first author Ke Wei Gong, a UCLA cardiology researcher. We wanted to measure what happens when these two sources of oxidation come into contact.

The scientists combined the pollutants and oxidized fats and cultured them with cells from the inner lining of human blood vessels. A few hours later, the team extracted DNA from the cells for genetic analysis.

We saw that the diesel particles and oxidized fats had worked in tandem to activate the genes that promote cellular inflammation a major risk factor for atherosclerosis, said Dr. Jesus Araujo, UCLA assistant professor of medicine and director of environmental cardiology at the Geffen School of Medicine.

The interaction left a genetic footprint that reveals how interaction between the particles and cholesterol accelerates the narrowing and blockage of the blood vessels, Araujo noted.

To duplicate these findings in living cells, the UCLA team exposed mice with high cholesterol to the diesel particles and saw activation of some of the same gene groups in the animals tissue.

Exactly how air pollutants cause cardiovascular injury is poorly understood, Nel said. But we do know that these particles are coated with chemicals that damage tissue and cause inflammation of the nose and lungs. Vascular inflammation in turn leads to cholesterol deposits and clogged arteries, which can give rise to blood clots that trigger heart attack or stroke.

The researchers next step will be to convert the genes responses to the pollutant-cholesterol combination into a biomarker that will enable physicians to easily evaluate air pollutions effect on health, especially cardiovascular disease.

Once a biomarker is developed, wed simply need to test a blood sample in order to measure a persons exposure to particulate matter and determine whether it has reached levels that require medical intervention, Araujo said.

The American Cancer Society has reported a 6 percent increase in heart- and lung-related deaths for every 10 micrograms per cubic meter rise in particulates.

Our results emphasize the importance of controlling air pollution as another tool for preventing cardiovascular disease, Gong said.

'Preconditioning' helps protect brain's blood vessels from stroke

Thu, 19 Jul 2007 04:00:00 PST

( from http://www.rxpgnews.com ) NEW YORK (July 17, 2007) -- Challenging brain tissue with a small noxious stimulus beforehand gives it a resilience that can lessen damage to blood vessels during a stroke, report researchers at Weill Cornell Medical College in New York City.

This preconditioning works along the theory of 'what doesn't kill me makes me stronger,' explains senior researcher Dr. Costantino Iadecola, the George C. Cotzias distinguished professor of neurology and neuroscience and Director of Neurobiology at Weill Cornell, and attending neurologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

We already knew that preconditioning helps minimize damage to heart tissue -- it's a strategy cardiologists routinely use today. And we know it can help protect brain cells -- neurons -- against stroke damage, Dr. Iadecola says. Now, besides illuminating mechanisms involved in this process, our new study in mice demonstrates that preconditioning also shields the brain's blood vessels from stroke injury, he explains.

The hope is that by studying this natural means of self-defense, we might develop potent pharmaceutical means of either preventing stroke or minimizing stroke damage, he says.

The findings appear as a special highlighted paper in the Journal of Neuroscience.

According to the National Stroke Association, stroke is the third leading killer of Americans and the number one cause of adult disability. And yet scientists have still not developed a truly effective means of treating these attacks.

We knew that preconditioning -- giving the brain a slight noxious stimulus beforehand -- can strengthen brain cells against damage from a larger insult later on. This phenomenon occurs naturally in the human brain, explains lead researcher Dr. Alexander Kunz of the University of Dresden, Germany. Dr. Kunz worked on the study while at Weill Cornell.

But exactly how does preconditioning work, and can it come to the aid of the brain's vasculature, as well

Based on their prior work, the researchers knew that the protective effect of preconditioning relies on a ubiquitous chemical in the blood called nitric oxide (NO). Injuries to tissues -- such as the ischemia that occurs in stroke -- activate certain enzymes that produce NO. This process also produces destructive, oxidative byproducts called free radicals.

According to the new study, NO combines with these free radicals to produce low levels of another molecule, called peroxynitrite.

At higher levels, peroxynitrite is a very dangerous chemical for tissues, Dr. Iadecola explains. But we discovered that at these lower concentrations, it's actually beneficial -- helping to preserve the function of blood vessels in the brain whenever a more toxic event occurs.

Normal mice given an inflammatory toxin called lipopolysaccharide (LPS) 24 hours before an induced stroke -- the preconditioning method used in this study -- had a 68 percent reduction in stroke intensity, the researchers found.

Preconditioning also boosted blood flow in areas of the brain unaffected by the stroke by 114 percent.

However, mice that were genetically engineered so that they could not produce NO gained no such advantage from preconditioning. This suggests that NO and its chemical offspring, peroxynitrite, are essential to this protective process.

Our study also demonstrates that preconditioning makes blood vessels more resilient against the damage caused by cerebral ischemia, just as it does for neurons, Dr. Iadecola notes. After preconditioning, the vessels of the brain are impervious to the effects of the stroke and continue to function at a nearly normal level. That's something no one had shown before.

He stressed that it's far too dangerous to give patients peroxynitrite, so the goal here is to figure out how low concentrations of the chemical work their protective magic.

What cell signaling mechanisms does it activate, for example If we could find that out, we might be able to create a pharmaceutical mimic that could protect stroke patients, Dr. Iadecola says.

The real novelty here is that we are looking for a stroke treatment that simply replicates strategies the brain is already using to protect itself, the researcher says. There's a large population out there at high risk for stroke, and we believe this approach could really help them. It might even help minimize brain tissue damage should any stroke occur.

Bak protein sets stressed cells on suicide path, researchers show

Thu, 12 Jul 2007 04:00:00 PST

( from http://www.rxpgnews.com ) When a cell is seriously stressed, say by a heart attack, stroke or cancer, a protein called Bak just may set it up for suicide, researchers have found.

In a deadly double whammy, Bak helps chop the finger-like filament shape of the cells powerhouse, or mitochondrion, into vulnerable little spheres. Another protein Bax then pokes countless holes in those spheres, spilling their pro-death contents into the cell.

We found out Bak has a distinct function in regulation of the mitochondrial morphology, says Dr. Zheng Dong, cell biologist at the Medical College of Georgia and the Veterans Affairs Medical Center in Augusta and corresponding author on a paper published this week in Proceedings of the National Academy of Sciences. Bax, on the other hand, is not involved in morphological regulation but needs to be there to puncture holes.

One has to break up, kind of soften, the mitochondria for injury, and the other one actually punches the holes to kill it, says Craig Brooks, MCG graduate student and the papers first author.

Bak and Bax have similar structures and scientists have long suspected they play major, similar roles in programmed cell death, or apoptosis. These two proteins are very important for mitochondrial injury and subsequent apoptosis, says Dr. Dong.

To stress cells, they blocked oxygen supplies and used the common chemotherapeutic agent cisplatin, then documented that filamentous mitochondria became fragmented very early and quickly in apoptosis. Ironically they also found the deadly fragmentation results from Baks interaction with mitochondria-shaping proteins called mitofusins, which help mitochondria keep their filamentous shape in non-stressed cells. Dr. Dong suspects Bak may also play a role in mitofusin regulation in normal, non-stressful conditions.

In fact, the researchers suspect Bak, Bax and the contents they spill into the cell all have roles in keeping a cell functioning until a stressor kicks in.

They probably are both kept in check normally in the cell by other proteins, and when something happens that overwhelms the cell, it activates Bak and Bax to start cell death, says Mr. Brooks. Some of the same proteins, cytochrome c is the big one, are needed for daily mitochondrial function like making energy, but if they are released from the mitochondria, they activate a cell killing or apoptotic pathway, says Dr. Dhong, referencing the contents that spill from punctured mitochondria.

Looking at kidney cells and neurons in a Bak deficient mouse, they also showed that Bak and Bax need each other to successfully spawn cell suicide. If you have Bak but not Bax, the mitochondria still fragment but they dont die; if you have Bax but not Bak, you still have punctures in the mitochondria but with low efficiency, says Mr. Brooks.

Now they want to know exactly how Bak interacts with mitofusins, how the interaction is regulated and how it affects mitochondrial morphology, physiology and pathology. Their long-term goal for better understanding the cell suicide mechanism is developing drugs to block it in the case of a stroke, for example, or induce it to kill cancer.

High blood pressure medication strategy proves effective in Hispanic women

Thu, 12 Jul 2007 04:00:00 PST

( from http://www.rxpgnews.com ) GAINESVILLE, Fla. -- Hispanic women with hypertension and coronary artery disease respond better to drug regimens aimed at controlling high blood pressure than non-Hispanic white women, University of Florida researchers report.

A UF study described in the current issue of the Journal of Womens Health revealed that when treated with either of two commonly prescribed medication strategies, Hispanic women achieved greater blood pressure control and were half as likely as white women to suffer adverse outcomes such as heart attack, stroke or death from any cause. The findings provide new data on a population of ethnic women who have been all but absent from such research.

The study is unique in that we enrolled a substantial number of women and a substantial number of Hispanic patients from a variety of different Hispanic regions. As a result, we have data that enabled us to really fully evaluate the treatment of hypertension in this ethnically diverse group, said Rhonda Cooper-DeHoff, Pharm.D, M.S., a research assistant professor of medicine and associate director of the clinical research program in cardiovascular medicine at UFs College of Medicine.

UF researchers studied 22,500 patients enrolled in the landmark International Verapamil SR-Trandolapril study, known as INVEST, and tracked a subgroup of 5,017 Hispanic and 4,710 non-Hispanic white women who were randomly assigned to a drug strategy containing either a sustained release form of the calcium antagonist verapamil or the beta-blocker atenolol.

The INVEST study enrolled more Hispanic patients than any other hypertension trial to date, Cooper-DeHoff said, and included Hispanic participants from the mainland United States, Puerto Rico, Cuba, Mexico, Canada, Guatemala, Panama and El Salvador.

After 24 months of follow-up, researchers found that both treatment strategies worked and worked better in the Hispanic women.

Blood pressure control, defined at less than 140/90 mmHg, was achieved in 75 percent of Hispanic women and 68 percent of non-Hispanic white women.

And despite having a higher prevalence of diabetes at baseline, only 5.7 percent of Hispanic women suffered from adverse cardiovascular outcomes, compared with 12.3 percent of non-Hispanic white women.

Cooper-DeHoff attributed the low incidence of adverse outcomes to the fact that Hispanic women enrolled in the study were younger. If follow-up had continued over a longer period of time, adverse outcomes in the Hispanic women may have increased, she said.

However, these women remained at a lower risk for these outcomes even after statisticians adjusted for age and other factors. Still, she warned that problems associated with diabetes are likely to show up in these patients down the road.

Diabetes in and of itself imparts significant future adverse cardiovascular outcomes, she said. These women should be well-monitored under the care of a physician so that they can prevent future cardiovascular morbidity and mortality related to hypertension and diabetes. Importantly, because the Hispanic population is the fastest-growing ethnic minority in the United States, Hispanics especially women should be included in future cardiovascular research in order to further our understanding of these high-risk diseases in Hispanic patients.

High blood pressure is becoming more prevalent in women across all ethnic groups, Cooper-DeHoff said. And although it is thought to actually be less common in Hispanic women, fewer Hispanics have been included in hypertension studies.

The INVEST findings are important because they demonstrate that this treatment for Hispanic women really pays off, said Thomas G. Pickering, M.D., D. Phil., director of the Center for Behavioral Cardiovascular Health at Columbia University Medical Center. Theyve got something really interesting with this study, and it wasnt something that could have been expected.

Method to prevent hemorrhagic complications of thrombolytic therapy of blood clots is discovered

Mon, 02 Jul 2007 04:00:00 PST

( from http://www.rxpgnews.com ) A novel method to prevent hemorrhagic complications of thrombolytic therapy of blood clots is discovered.

Blood clot dissolution by thrombolytic therapy is an approved, safe and efficaceous therapy of acute ischemic stroke. It is in routine use world-wide, and prevents individuals from stroke-related long-term disability. Many safe therapy forms, however, are often associated with hazards, and therefore indications for therapy must be weighed on an individual basis. In stroke thrombolysis, it is the risk of perithrombolytic hemorrhage formation and expansive brain edema that are most feared complications, and may preclude from administering the therapy. Even after proper precautions, perithrombolytic hemorrhages occur in 6 to 10 % of treated patients. Therefore, experimental research is needed to clarify the mechanisms leading to these complications.

The now reported study led by Dr. Perttu J. Lindsberg from the Helsinki University Central Hospital investigated thrombolytics-related brain hemorrhage formation in an experimental stroke model in rats. It found that, in addition to the clot lysing effect, the drug used for this purpose, alteplase (recombinant tissue plasminogen activator) also possesses proinflammatory properties and activates and degranulates mast cells, a kind of tissue-based immune cell. On degranulation, mast cells release potent enzymes that cleave proteins (eg, chymase, tryptase, and metalloproteases) in the vessel wall. The result is increased vascular permeability, which can lead to hazardous brain edema and potentially to frank brain hemorrhage formation. A pharmacological mast cell stabilizer, cromoglycate, was administered before alteplase, and it reduced these detrimental effects significantly and led to improved neurological outcome and reduced mortality.

The amount of brain hemorrhage was reduced by 97% at 3 hours, by 76% at 6 hours, and by 96% after 24 hours of follow-up. Ischemic brain edema was reduced by 80% at 3 hours, by 55% at 6 hours and by 85% after 24 hours of follow-up. The mortality in control group was 29%, 64% in alteplase group, and 0% in a group treated with a combination of alteplase and cromoglycate. kromoglikaatti+alteplaasiryhmässä 0%). Furthermore, genetically engineered animals were used which lacked mast cells, and they showed minimal brain edema and alteplase-related hemorrhage formation. They also had improved neurological outcome and mortality compared with wild-type littermates. In addition to proteolytic enzymes, mast cells release vasodilators such as histamine as wellas heparin (s.c. blood thinning anticoagulant drug), which may locally prevent blood coagulation, predispose to bleeding and edema formation and ultimately lead to hazardous expansion of hemorrhagic and edematous brain events. The intracranial space is tight and does not allow expansion of its tissue content without harmful and potentially fatal consequences.

This study revealed a novel proinflammatory cellular mechanism related to an every-day dilemma in routine patient care that may provide a novel pharmacological target if confirmed in the clinical setting. At best, mast cell stabilization could eventually be applied as an adjuvant to thrombolysis.

Pneumonia- major cause for re-admission after strokes

Mon, 25 Jun 2007 11:35:46 PST

( from http://www.rxpgnews.com ) Stroke is a leading cause of hospital admission among older adults. Yet more hospital readmissions after stroke are for pneumonia or for heart disease than for another stroke, according to a study published in the June 2007 issue of the journal Stroke. This finding may alter the standard medical management of post-stroke patients.

"Few stroke patients survive five years without a readmission to the hospital. Common wisdom has been that patients who have had a stroke are likely to return to the hospital for treatment of another stroke. Our study found that, surprisingly, the most common reasons for readmission to the hospital were non-neurological, with pneumonia or other respiratory problem leading the list of reasons," said the studyâs first author, Dawn M. Bravata, M.D., Indiana University School of Medicine associate professor of medicine.

The researchers followed 2,603 stroke patients discharged from the hospital and found that more than half had died or been readmitted to a hospital at least once during the first year after discharge. And by five years out, almost 9 out of 10 stroke survivors had died or been readmitted to a hospital. These readmissions were more than twice as likely to be for pneumonia as for another stroke.

"Physicians treating stroke patients need to continue focusing on preventing a recurrence of stroke. We now see that, in addition, we should also be thinking about the other conditions that are causing hospital readmission in this vulnerable group," she said.

Dr. Bravata, who is an investigator with the Center on Implementing Evidence-based Practice at the Roudebush VA Medical Center in Indianapolis, currently is working on a follow-up study to see whether certain interventions, such as pneumonia and influenza vaccinations, can lower hospital readmissions for stroke patients.

"These readmissions are an enormous burden on patients, families and the health-care system. We may have a previously unrecognized window of opportunity beginning when the patient is first hospitalized for stroke to decrease the likelihood for hospital readmission," Dr. Bravata said.

More women than men having mid-life stroke

Wed, 20 Jun 2007 04:00:00 PST

( from http://www.rxpgnews.com ) ST. PAUL, Minn -- More women than men appear to be having a stroke in middle age, according to a study published June 20, 2007, in the online edition of Neurology®, the medical journal of the American Academy of Neurology. Researchers say heart disease and increased waist size may be contributing to this apparent mid-life stroke surge among women.

For the study, researchers analyzed data from 17,000 people over the age of 18 who participated in the National Health and Nutrition Examination Survey. Of the participants, 606 people experienced a stroke.

The study found women in the 45 to 54 age range were more than twice as likely as men in the same age group to have had a stroke. There were no sex differences in stroke rates found in the 35 to 44 and the 55 to 64 age groups.

While our analysis shows increased waist size and coronary artery disease are predictors of stroke among women aged 45 to 54, it is not immediately clear why there is a sex disparity in stroke rates among this age group, said study author Amytis Towfighi, MD, with the Stroke Center and Department of Neurology at the University of California at Los Angeles, and member of the American Academy of Neurology. While further study is needed, this mid-life stroke surge among women suggests prompt and close attention may need to be paid to the cardiovascular health of women in their mid-30s to mid-50s with a goal of mitigating this burden.

In addition, Towfighi says several vascular risk factors including systolic blood pressure and total cholesterol levels increased at higher rates among women compared to men in each older age group.

For instance, with each decade, mens blood pressure increased by an average of four to five points, whereas womens blood pressure increased by eight to 10 points. Similarly, men had significantly higher total cholesterol levels than women at age 35 to 44, but mens total cholesterol remained stable while womens total cholesterol increased by 10 to 12 points with each decade, so that by age 55 to 64, women had significantly higher total cholesterol than men, said Towfighi.

Towfighi says the study also found a greater than expected stroke surge among men who were nearing the end of middle age. Men aged 55 to 64 were three times more likely than men aged 45 to 54 to have had a stroke. Towfighi says the reasons behind this increase warrant further investigation.

Postmenopausal hormone therapy and coronary disease -- the truth of the matter

Wed, 20 Jun 2007 04:00:00 PST

( from http://www.rxpgnews.com ) With each new publication of coronary artery disease (CAD) data from the Womens Health Initiative (WHI) study, the inevitable reaction is Why on earth did the WHI investigators claim in 20022004 that postmenopausal hormone therapy has deleterious effects on the risk for CAD, when, from the beginning, they were aware of the importance of the age factor in this clinical scenario. Women in the age group of 5059 years who participated in the estrogen-alone arm of the WHI study were asked immediately after the early cessation of the trial to become part of an ancillary study the WHI-CACS which looked at the magnitude of coronary calcifications measured by ultra-fast coronary CT. Coronary calcium deposits develop as part of the atherosclerosis process and correlate well with findings of coronary angiography.

The results of WHI-CACS, now published in the New England Journal of Medicine [1] are very encouraging, since women who were randomized to the estrogen arm of the WHI had significantly smaller calcification scores than their counterparts in the placebo arm. The effect was recorded for all degrees of severity, with estrogen users having a 2030% reduction in the likelihood of being categorized as having a mild to moderate increase in calcification scores (less than 100), and a more than 50% reduction in the likelihood of being categorized as advanced cases with calcification scores above 100. This study re-affirms what was actually known for many years, based on animal data and observational studies in women. Estrogen has a wide range of well-documented beneficial metabolic and vascular effects: it reduces the pace of accumulation of atherosclerosis, and decreases the risk of coronary events, provided that treatment is started early in the menopause. In addition, the CT in the WHI-CACS was performed at a mean age of 64.8 years, 7.4 years after randomization to the WHI trial, which suggests a new safety margin for age and duration of estrogen therapy, as women can be reassured that estrogen therapy is cardioprotective at least until age 65.

One of the main arguments that were raised at the time of publication of the preliminary data of the WHI 5 years ago, in attempt to explain the disconcordance between the results of previous large-scale, long-term, observational studies and the WHI cardiac data, was that randomized, placebo-controlled trials are always better and suffer less bias. With randomized trials being Level I evidence and observational trials considered Level II evidence, devaluation of good observational data became state-of-the-art. The recent post-hoc analyses from WHI show that, by the end of the day, the observational studies did give valuable information, which was comparable to that obtained by the randomized trials.

Even for the issue of coronary calcifications and hormone therapy, a literature search shows that lower grade encouraging clinical data were there for at least 10 years. Clearly, a real long-term, randomized, double-blind, placebo-controlled study on hormone therapy cannot be performed. The IMS therefore suggests that available long-term data from the Nurses Health Study and other major observational studies should be considered while making decisions on hormone therapy in clinical practice. Since most, if not all, women do not start hormone therapy at an old age, safety concerns on its possible adverse cardiac effects are actually invalid for the vast majority of hormone users. In fact, treatment seems to be associated with reduction of risk for coronary artery disease if initiated early.

Standards for measuring narrowing of carotid arteries too aggressive

Thu, 07 Jun 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Standards for the use of ultrasound as a screening tool to measure narrowing of the carotid artery may be too aggressive, resulting in some needless follow-up tests and procedures according to researchers at the University of Chicago Medical Center. Narrowing of the carotid can be a precursor to a stroke.

Hisham Bassiouny, MD, director of the non-invasive vascular lab and interim section chief of vascular surgery at the University of Chicago, presented the findings of a study today at the Society for Vascular Surgerys Annual Meeting in Baltimore.

These standards, used by the majority of vascular laboratories around the country since the early 1980s, were based on the use of angiography, a medical imaging technique in which an X-ray picture is taken to visualize the inner opening of blood filled structures.

The limitation with angiography is that you had to guess how far the outer wall of the artery was beyond the arterys channel to determine the precise degree of artery blockage, he says. That was a guess, an estimate. Based upon that subjective estimate, formulas were developed to look at the velocity of blood flow in the artery and determine how much narrowing existed. These formulas became the standard used to this day. However, imaging technology is much better today than when these standards were developed.

The researchers studied 74 patients with narrowing of the carotid arteries. They used ultrasound to assess the narrowing and compared the results from ultrasound to those found using CT angiography. Both techniques produced similar results, with nearly identical measures of the size of the channel inside the artery.

Further study of another 337 mild, moderate, and severely narrowed arteries, using high-resolution ultrasound techniques, looked at the diameter of the outer wall of the arteries. Standards were developed according to each individualized measurement. The results using the new standards indicated that blood flow was often better than the old standards would predict.

Previously, the researchers found that a peak systolic blood velocity of 125 centimeters per second indicated the artery was narrowed by at least 50 percent. Now, they think a peak systolic blood velocity of 155 centimeters per second indicates a 50 percent narrowing.

As a result, weve changed the standards in our vascular lab, says Bassiouny. We hope these new standards will be adopted everywhere. Such a move would save money and spare at least some patients from unnecessary procedures and tests.

New clues to stroke role in Alzheimer's

Wed, 06 Jun 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Researchers have discovered key details of how stroke or traumatic brain injury can trigger Alzheimers disease (AD) by enhancing formation of brain-clogging amyloid plaques. Their experiments established that executioner enzymes that kill brain cells during stroke or head trauma also interfere with the normal disposal of an enzyme that helps generate plaque. This interference increases the level of the enzyme in brain cells, they found.

The researchers, led by Giuseppina Tesco and Rudolph Tanzi of Massachusetts General Hospital, reported their findings in the June 7, 2007, issue of the journal Neuron, published by Cell Press.

The researchers sought to understand the mechanism by which stroke or brain injury causes the increase of an enzyme called BACE in the brain. BACE is a protein-cleaving enzyme that snips apart a brain protein called amyloid precursor protein to form a shorter protein called A beta peptide. It is this A beta peptide that is the building block for the amyloid plaques that are a hallmark of AD.

The researchers discovered that particular enzymes produced during brain injury, called caspases, somehow also enable BACE to linger in brain cells. Caspases are so-called executioner enzymes that destroy brain cells such as those damaged by oxygen deprivation during stroke.

In further exploring the link between caspase activation and higher BACE levels, the researchers found that one of the proteins snipped apart by caspase activity is GGA3. This protein is an adaptor protein necessary for shepherding BACE to the cells garbage disposal machinery, the lysosome. The researchers found that caspase snipping of GGA3 not only eliminates GGA3's ability to tag BACE for destruction but that the resulting fragments of GGA3 actively interfere with BACE disposal.

To test the role of GGA3, the researchers silenced activity of the GGA3 gene in brain cells, finding that the silencing caused increased levels of BACE and the amyloid proteins.

And they found that inducing strokes in rats caused GGA3 to be degraded and BACE levels to increase. Finally, when they analyzed brain tissue from people with AD, they found decreases in GGA3 levels that were inversely correlated with increases in BACE.

The researchers pointed out that studies have shown that individuals with AD and cerebrovascular pathologies show greater cognitive impairment than those exhibiting either pathology alone. These studies indicate that there is an additive or synergistic interaction between AD and cerebrovascular pathologies.

Furthermore, evidence is accumulating that stroke and transient ischemic attacks significantly increase the risk of AD in elderly individuals. Thus, stroke may represent either a precipitating or a triggering event in AD, they wrote.

In summary, wrote Tesco, Tanzi, and their colleagues, other researchers studies, taken together with our current data, suggest that accumulative insults to the brain over ones lifetime would progressively increase risk for AD by elevating cerebral A beta accumulation via BACE stabilization owing to caspase-mediated depletion of GGA3.

Study outlines how stroke, head injury can increase risk of Alzheimer's disease

Wed, 06 Jun 2007 04:00:00 PST

( from http://www.rxpgnews.com ) Researchers from the MassGeneral Institute for Neurodegenerative Disorders (MGH-MIND) have discovered how the death of brain cells caused by a stroke or head injury may cause generation of amyloid-beta protein the key component of senile plaques seen in the brains of patients with Alzheimer's disease. Their report appears in the June 7 issue of the journal Neuron.

We have discovered how a stroke can trigger a series of biochemical events that increase amyloid-beta production in the brain, says Giuseppina Tesco, MD, PhD, of the MGH-MIND Genetics and Aging Research Unit, the papers lead author. These findings raise the prospect of novel therapies that could interfere with this process and reduce the risk of Alzheimers disease in stroke or head trauma patients.

It has been known for several years that strokes and head injuries can increase the risk of Alzheimers disease, but the mechanism underlying that increased risk has not been understood. Alzheimer's disease is characterized by plaques within the brain of amyloid-beta protein, which is toxic to brain cells. Amyloid-beta is formed when the larger amyloid precursor protein (APP) is clipped by two enzymes beta-secretase, also known as BACE, and gamma-secretase which releases the amyloid-beta fragment. The usual processing of APP by an enzyme called alpha-secretase produces an alternative, non-toxic protein.

The MGH-MIND team previously reported that cellular BACE levels are normally controlled by the enzymes breakdown in compartments called lysosomes, a process that is disrupted if a molecular signal on the enzyme is altered. That signal binds to GGA proteins, which are required for the transport of several types of enzymes into lysosomes. One of these proteins, GGA3, can be degraded by caspase, an enzyme takes part in the cell-death process called apoptosis.

In a series of experiments the MGH-MIND researchers revealed how cell death caused by a brain injury, including a stroke, can lead to the production of amyloid-beta. Damaged brain cells undergo apoptosis, releasing caspase which also breaks down GGA3. Without enough GGA3 to help transport BACE to lysosomes, levels of BACE rise and lead to increased amyloid-beta production. Amyloid-beta itself is toxic to brain cells, so it may cause further apoptosis, leading to a vicious cycle of continued cell death and amyloid-beta production.

The importance of GGA3s control of BACE levels was supported by the observation that, in brain tissue from Alzheimers patients, reductions in GGA3 corresponded with elevations in BACE, particularly in those areas most affected by the disease.

Our findings also shed new light on how the aged brain becomes more vulnerable to AD, since any insult to the brain head injury, stroke, or the mini-strokes called TIAs can set off this process and turn up BACE activity, says Rudolph Tanzi, PhD, director of the Genetics and Aging Research Unit and senior author of the Neuron paper. Therapies that protect GGA3 from caspase cleaving might be able to reduce the risk of AD or the more transient type of dementia that can occur after such injuries. Tanzi is a professor of Neurology at Harvard Medical School, where Tesco is an assistant professor.