Effect of fingolimod on MRI outcomes in patients with paediatric-onset multiple sclerosis: results from the phase 3 PARADIGMS study

OBJECTIVE

PARADIGMS demonstrated superior efficacy and comparable safety of fingolimod versus interferon β-1a (IFN β-1a) in paediatric-onset multiple sclerosis (PoMS). This study aimed to report all predefined MRI outcomes from this study.

METHODS

Patients with multiple sclerosis (MS) (aged 10-<18 years) were randomised to once-daily oral fingolimod (n=107) or once-weekly intramuscular IFN β-1a (n=108) in this flexible duration study. MRI was performed at baseline and every 6 months for up to 2 years or end of the study (EOS) in case of early treatment discontinuation/completion. Key MRI endpoints included the annualised rate of formation of new/newly enlarging T2 lesions, gadolinium-enhancing (Gd+) T1 lesions, new T1 hypointense lesions and combined unique active (CUA) lesions (6 months onward), changes in T2 and Gd+ T1 lesion volumes and annualised rate of brain atrophy (ARBA).

RESULTS

Of the randomised patients, 107 each were treated with fingolimod and IFN β-1a for up to 2 years. Fingolimod reduced the annualised rate of formation of new/newly enlarging T2 lesions (52.6%, p<0.001), number of Gd+ T1 lesions per scan (66.0%, p<0.001), annualised rate of new T1 hypointense lesions (62.8%, p<0.001) and CUA lesions per scan (60.7%, p<0.001) versus IFN β-1a at EOS. The percent increases from baseline in T2 (18.4% vs 32.4%, p<0.001) and Gd+ T1 (-72.3% vs 4.9%, p=0.001) lesion volumes and ARBA (-0.48% vs -0.80%, p=0.014) were lower with fingolimod versus IFN β-1a, the latter partially due to accelerated atrophy in the IFN β-1a group.

CONCLUSION

Fingolimod significantly reduced MRI activity and ARBA for up to 2 years versus IFN β-1a in PoMS.

Statistical evaluation of biomedical studies

The aim of this chapter is to familiarize the reader with the basic information and common statistical analyses used in medical research. The chapter will aid in deciding what type of analyses best fit the study data and how each analysis differs. The chapter was written to be user-friendly from a medical research and statistical consultant perspective.

Evaluation of topically administered diclofenac liposomal cream for treatment of horses with experimentally induced osteoarthritis

OBJECTIVE

To assess the clinical, biochemical, and histologic effects of topically administered diclofenac liposomal cream (DLC) in the treatment of horses with experimentally induced osteoarthritis.

ANIMALS

24 horses.

PROCEDURES

Osteoarthritis was induced arthroscopically in 1 middle carpal joint of all horses. Eight horses treated with DLC were given 7.3 g twice daily via topical application. Eight horses treated with phenylbutazone were given 2 g orally once daily. Eight control horses received no treatment. Evaluations included clinical, radiographic, magnetic resonance imaging, synovial fluid, gross, and histologic examinations as well as histochemical and biochemical analyses.

RESULTS

No adverse treatment-related events were detected. Horses that were treated with DLC or phenylbutazone had significant clinical improvement of lameness, unlike the control horses. Treatment with DLC induced significant improvement in staining and total articular glycosaminoglycan content, compared with no treatment. Treatment with phenylbutazone induced significant reduction in synovial fluid prostaglandin E2 concentration, compared with DLC and no treatment. Treatment with DLC induced significantly less radial carpal bone sclerosis and overall gross cartilage erosion, compared with phenylbutazone.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that DLC had both clinical sign-modifying and disease-modifying effects. Only clinical sign-modifying effects were detected in association with phenylbutazone administration. Treatment with DLC had significant beneficial effects, compared with phenylbutazone, and no detrimental effects. Results suggested that DLC is a viable therapeutic option for horses with osteoarthritis.

Usefulness of increased skin cholesterol to identify individuals at increased cardiovascular risk (from the Predictor of Advanced Subclinical Atherosclerosis study)

In patients with symptomatic coronary heart disease, skin cholesterol (SC) content is associated with the presence and extent of coronary artery disease; however, its relation to subclinical arterial disease in asymptomatic patients is unknown. The purpose of this study was to determine the relations between SC and carotid intima-media thickness (CIMT) in asymptomatic subjects across a wide range of cardiovascular risk. SC was measured using a noninvasive assay. CIMT and carotid plaque presence were determined by high-resolution B-mode ultrasound. Associations among SC, CIMT, carotid plaque presence, and cardiovascular risk factors were evaluated by multivariable logistic regression analyses. SC and CIMT were measured in 565 asymptomatic subjects (57 +/- 10 years of age, 38% women) from 6 sites in North America. The mean Framingham 10-year cardiovascular risk was 8.4 +/- 7.2%. A 10-U increase in SC was associated with a 12% increase in the odds of having increased CIMT (p = 0.006) and a 15% increase in carotid plaque presence (p = 0.002). Odds ratios (95% confidence intervals) associated with SC >110 U were 2.19 (1.25 to 3.85, p = 0.006) for increased CIMT and 2.89 (1.61 to 5.19, p <0.001) for carotid plaque presence. In conclusion, SC identified the presence of advanced subclinical atherosclerosis. The relations among increasing SC, increasing CIMT, and carotid plaque presence were consistent across all levels of cardiovascular risk and were independent of cardiovascular risk factors. SC may be a useful test for cardiovascular risk prediction.

Skin cholesterol adds to Framingham risk assessment

INTRODUCTION

It has been demonstrated that skin tissue cholesterol (SkinTc) is associated with angiographic disease. Now, we further delineate the relative risk of multivessel disease (>50% stenosis in at least two vessels) in the conjoint presence of high SkinTc and high traditional risk burden.

METHODS

Patients scheduled for angiography (N = 649) had SkinTc measured immediately prior to the procedure. Patients were classified according to the presence of high (>110) SkinTc and high (>10) Framingham global risk scores. Multivariable logistic regression models were used to estimate relative risk of multivessel disease for patients with isolated high skin tissue cholesterol, isolated high Framingham risk or conjoint high skin tissue cholesterol and high Framingham risk (each compared to neither factor elevated).

RESULTS

The mean age was 63 +/- 12 years and 33% (n = 214) were women. Thirty seven percent (n = 237) had angiographically determined multivessel disease. Patients with isolated high SkinTc showed a relative risk of multivessel disease of 1.6 (95% CI = 1.0-2.4), while patients with isolated high Framingham risk had an odds ratio of 1.8 (CI = 1.0-3.4). However, when both scores were elevated, risk of multivessel disease was increased 4.3 times (CI = 2.6-7.2) compared to neither elevated.

CONCLUSIONS

We see an independent, additive risk of concurrent multivessel disease when Framingham risk and skin cholesterol are both elevated. Skin tissue cholesterol may have value in further stratifying subjects with Framingham scores >10.

A randomized, double-blind, placebo-controlled, parallel-group study to assess the efficacy and safety of dual ACE/NEP inhibitor GW660511X in mild-to-moderate hypertensive patients

This multicentre, double-blind, placebo-controlled, parallel-group study determined the efficacy and safety of GW660511 200 mg, a dual inhibitor of angiotensin-converting enzyme (ACE) and neutral endopeptidase (NEP), in mild-to-moderate hypertensive patients (diastolic blood pressure (DBP), > or =90 and < or =109 mm Hg; systolic blood pressure (SBP), > or =150 and < or =180 mm Hg). After a single-blind 2- to 4-week placebo run-in period, 123 patients (aged 18-65 years) were randomized to either placebo (n=62) or to active treatment (n=61) consisting of two consecutive 3-day dose titration periods of GW660511X 50 mg once daily and 100 mg once daily followed by GW660511X 200 mg once daily for 14 days. GW660511X 200 mg significantly lowered (baseline and placebo-corrected) both trough mean cuff SBP (-8.00 mm Hg, P=0.002) and DBP (-5.38 mm Hg, P=0.003). GW660511X 200 mg significantly reduced placebo-corrected mean 24-h and daytime but not night-time ambulatory SBP and DBP. Over the 0-24 h time period following GW660511X 200 mg, there were significant (P<0.001) reductions in serum ACE activity and significant (P<0.001) increases in plasma ANP concentration compared with placebo in terms of both peak and trough effects. In addition, treatment with GW660511X 200 mg significantly (P=0.003) increased (placebo-corrected, 1.52-fold) urinary excretion of cGMP over the 0-24 h interval. Treatment-related adverse events were experienced by 43% of the patients administered GW660511X 200 mg and 44% of those dosed with placebo with headache the most commonly reported. In conclusion, GW660511X 200 mg is an effective antihypertensive in mild-to-moderate hypertensive patients with potent effects on biological markers of ACE and NEP inhibition.

Elevated skin tissue cholesterol levels and myocardial infarction

BACKGROUND

Skin cholesterol has been associated with coronary artery disease, extent of angiographic disease and inflammatory markers such as hs-CRP. Based on these findings we sought to determine whether skin cholesterol was associated with myocardial infarction (MI).

METHODS

Patients (N = 649) underwent diagnostic catheterization and concurrent skin cholesterol measurement. History of MI was determined at the time of hospitalization.

RESULTS

Patients with a history of MI (n = 225, 35%) had significantly higher skin cholesterol than those without MI (127+/-29 versus 120+/-20, p = 0.002). The odds ratio for high skin cholesterol (for MI) was 1.6 (95% CI = 1.1, 2.6; p = 0.01) after adjustment for traditional risk and extent of angiographic disease.

CONCLUSION

Skin cholesterol may indicate increased risk of coronary-related events rather than simply the presence of angiographic narrowing.

Impact of nonprescriptive factors on low-density lipoprotein cholesterol reduction with statins

Nonprescriptive factors, including patient adherence, can affect the fluctuations in low-density lipoprotein (LDL) cholesterol observed in the clinical setting. In 241 statin-treated patients, although drugs and doses remained fixed, 57% of patients initially successful in reaching LDL cholesterol targets showed subsequent increases in LDL cholesterol. Conversely, 60% of patients who initially failed to reach targets had subsequent reductions in LDL cholesterol, with nearly 1/3 eventually attaining their LDL cholesterol goals.

Skin tissue cholesterol (SkinTc) is related to angiographically-defined cardiovascular disease

Parallel changes associated with aging found in the vasculature and skin at necropsy, have prompted small preliminary studies to assess the relation between skin tissue cholesterol (SkinTc) and cardiovascular disease. While these studies have been suggestive, no formal investigation is available to test this association. It would, therefore, be valuable to determine whether a relation between SkinTc and angiographic narrowing actually exists, the latter representing one accepted measurement of coronary atherosclerosis.

METHODS

Patients at three hospitals undergoing coronary angiography and not on lipid altering agents (n = 649) were examined for skinTc using a non-invasive method. Vessels were evaluated manually (number with stenosis > or = 50%). Clinical characteristics, current medication use, and Framingham global risk score were recorded.

RESULTS

SkinTc was significantly higher in patients with angiographic disease (124 +/- 30 vs. 118 +/- 30, P = 0.02). After adjustment for traditional coronary artery disease risk factors, SkinTc provided 7% additional risk (per 10 SkinTc units) for angiographic disease.

CONCLUSION

SkinTc, measured with a non-invasive method, is associated with the presence of coronary artery disease as determined by catheterization. Such an assay may eventually help stratify patient risk and target prevention efforts.

A comparison of fluvoxamine, fluoxetine, sertraline and paroxetine examined by observational cohort studies

OBJECTIVE

To compare the safety and side-effect profiles of the four selective serotonin reuptake inhibitor antidepressants (SSRIs), fluvoxamine, fluoxetine, sertraline and paroxetine.

METHODS

The results from four observational cohort studies of the four SSRIs were compared. Each of these studies was conducted by Prescription-Event Monitoring (PEM). The exposure data were derived from general practitioner (GP) prescriptions confidentially supplied by the Prescription Pricing Authority (PPA) in England. Outcome data were obtained from questionnaires (green forms) on which the prescribing doctor recorded event data. The main findings comprised demographic information, including patients' date of birth and sex; the indication for prescribing the monitored drug; the effectiveness of the drug as perceived by the GP; the reasons for stopping treatment and all events recorded during and after treatment.

RESULTS

The final cohort for each of the four SSRIs exceeded 10,000 patients. The sex, age distributions and indications for prescribing the four SSRIs were very similar. Only 36% of the GPs expressing an opinion reported fluvoxamine as effective, compared with approximately 60% for fluoxetine, sertraline and paroxetine. Fluvoxamine was associated with a higher incidence of adverse events than the other three SSRIs. Nausea/vomiting was both the most frequent clinical reason for stopping all four SSRIs and the most frequently reported clinical event. Adverse events reported in patients aged 70 years and over were comparable with the events reported for the total cohorts. Differences were identified between the four SSRIs for less frequently reported adverse events. Withdrawal symptoms were significantly more frequent with paroxetine than the other three SSRIs.

CONCLUSIONS

The data from the four studies were comparable in terms of age distribution, sex of patients and indication for prescribing the drugs. Fluvoxamine had a considerably higher incidence of side-effects associated with its use than the other three SSRIs. The side-effect profiles of the four SSRIs were comparable for frequently reported events. Important differences were identified between the four SSRIs in respect of less frequently reported events. This study suggests that fluvoxamine compares unfavourably with fluoxetine, sertraline and paroxetine, both in terms of reported effectiveness and the incidence of adverse events. Biases possibly affecting the comparisons involved in this study are unlikely to account for the observed differences between fluvoxamine and the other three SSRIs.

Relation of homocysteine and C-reactive protein to urinary albumin loss

This study shows that elevated high-sensitivity C-reactive protein and plasma total homocysteine contribute independently to the likelihood of an increased urinary albumin:creatinine ratio. This result suggests that total homocysteine and C-reactive protein may be acting by separate mechanistic pathways.

Association Between Apolipoprotein E Alleles and Calcific Valvular Heart Disease

Background— Studies on apolipoprotein E (apoE) alleles have reported an increased risk of coronary heart disease in patients with the apoE4 allele. Given the risk factor and histological similarities between coronary and calcific valvular heart disease (aortic stenosis [AS] and mitral annular calcification [MAC]), we postulated that apoE alleles might be associated with the development of these valvular lesions.

Methods and Results— We evaluated the association between apoE alleles and calcific valvular lesions in 802 patients undergoing transthoracic echocardiography using logistic regression analyses. No difference was noted in genotype distribution ( P =0.59) or prevalence of apoE4 between those with or without MAC (30% versus 27%, respectively; P =0.57). Compared with patients without AS, the genotype distribution of patients with AS differed significantly ( P =0.03), with increasing prevalences of the apoE 4 allele (27% in those without versus 40% in those with AS; P =0.01). In multivariate analyses adjusting for age, gender, low-density lipoprotein cholesterol levels, and coronary artery disease, increasing age and the apoE4 allele were significant independent predictors of AS (odds ratio, 1.94; 95% confidence interval, 1.01 to 3.71; P =0.046), whereas the apoE4 allele was not predictive of MAC.

Conclusions— These findings support extension of the importance of the apoE4 allele beyond atherosclerosis and Alzheimer’s disease to calcific AS.

Relation of albumin/creatinine ratio to C-reactive protein and to the metabolic syndrome

We hypothesized that the association of high sensitivity C-reactive protein (CRP) with urinary albumin excretion (UAE) is predominately mediated through its correlation with the metabolic syndrome. Serum CRP and urine albumin:creatinine ratios (ACR) from 720 preventive cardiology patients were analyzed to estimate age- and gender-adjusted relative risk of high CRP and metabolic syndrome for high ACR. These data demonstrate that CRP independently predicts the presence of UAE, a marker of endothelial dysfunction.

Association of nitrotyrosine levels with cardiovascular disease and modulation by statin therapy

CONTEXT

Formation of nitric oxide-derived oxidants may serve as a mechanism linking inflammation to development of atherosclerosis. Nitrotyrosine, a specific marker for protein modification by nitric oxide-derived oxidants, is enriched in human atherosclerotic lesions and low-density lipoprotein (LDL) recovered from human atheroma.

OBJECTIVES

To determine whether systemic levels of nitrotyrosine are associated with the prevalence of coronary artery disease (CAD) and are modulated by hydroxymethylglutaryl coenzyme-A reductase inhibitor (statin) therapy.

DESIGN, SETTING, AND PATIENTS

A case-control and interventional study at 2 urban tertiary-care referral centers; recruitment for each was from June 1, 2001, until January 1, 2002. For the case-control study, 100 case-patients with established CAD and 108 patients with no clinically evident CAD were recruited consecutively. In the interventional study, participants aged 21 years or older with hypercholesterolemia (LDL cholesterol > or =130 mg/dL [> or =3.5 mmol/L]) underwent nutrition and exercise counseling. Those whose levels did not decrease with 6 to 8 weeks were enrolled in the study (n = 35). For 12 weeks, they received 10 mg/d of oral atorvastatin therapy.

MAIN OUTCOME MEASURES

In the case-control study, the association between systemic levels of protein-bound nitrotyrosine, CAD risk, and presence of CAD. In the interventional study, the change in nitrotyrosine, lipoprotein, and C-reactive protein (CRP) levels.

RESULTS

Nitrotyrosine levels were significantly higher among patients with CAD (median 9.1 micromol/mol [interquartile range, 4.8-13.8 micromol/mol] tyrosine vs 5.2 micromol/mol [interquartile range, 2.2-8.4 micromol/mol]; P<.001). Patients in the upper quartile of nitrotyrosine (29%; P<.001) had a higher odds of CAD compared with those in the lowest quartile (unadjusted odds ratio, 6.1; 95% confidence interval, 2.6-14.0; P<.001). In multivariate models adjusting for Framingham Global Risk Score and CRP, upper quartiles of nitrotyrosine remained associated with CAD (odds ratio, 4.4; 95% confidence interval, 1.8-10.6; P<.001). Statin therapy reduced nitrotyrosine levels significantly (25%; P<.02) with a magnitude similar to reductions in total cholesterol levels (25%; P<.001) and LDL particle number (29%; P<.001) yet were independent of alterations in lipoproteins and inflammatory markers like CRP.

CONCLUSIONS

The findings from this preliminary study indicate that nitrotyrosine levels are associated with the presence of CAD and appear to be modulated by statin therapy. These results suggest a potential role for nitric oxide-derived oxidants as inflammatory mediators in CAD and may have implications for atherosclerosis risk assessment and monitoring of anti-inflammatory actions of statins.

Statins do not meet expectations for lowering low-density lipoprotein cholesterol levels when used in clinical practice

BACKGROUND

Statins have become a mainstay in the treatment of hyperlipidemia, based on their potency and favorable side-effect profile. Drug choice is presumed to be guided by the estimated degree of low-density lipoprotein (LDL) cholesterol lowering required in a particular patient and the projected efficacy of any drug-dose combination, as contained in the package inserts for each medication. We investigated whether these expectations were met in a clinical practice.

METHODS

Data were analyzed for 367 hyperlipidemic patients in a preventive cardiology practice who were not taking statins at entry, who were given a standard statin dose at their first visit, and who had at least one follow-up visit on the same drug/dose. Expected LDL cholesterol reductions were calculated for each patient based on guidelines in the package inserts for each drug.

RESULTS

The mean (+/-SD) observed LDL cholesterol reduction of 26% +/- 20% was significantly less than expected (34% +/- 7%, P < 0.001). The ratio of observed to expected reduction was not different for the three statins used (atorvastatin, 0.79 +/- 0.48; simvastatin, 0.88 +/- 0.61; pravastatin, 0.75 +/- 0.69; P = 0.39).

CONCLUSIONS

The use of statins in a clinical practice led to observed reductions in LDL cholesterol level that were significantly less than those projected by package insert guidelines. We believe this gap reflects the reduced patient compliance frequently observed in clinical practice settings, rather than any inherent difference in statin responsiveness of a practice versus a trial population. Physicians should be aware of this disparity when using statins in the clinical setting.

Fiber-multivitamin combination therapy: a beneficial influence on low-density lipoprotein and homocysteine

Proven effective alternative and adjunctive therapies for lipid lowering could be beneficial for patients with hyperlipidemia. We evaluated a 90% soluble fiber for its ability to alter lipid, lipoprotein, and homocysteine levels in the setting of coadministered folate and B vitamins. Patients (n = 119) were randomized to either the fiber and vitamin combination, or placebo. Fasting lipid, glucose, and homocysteine concentrations, and body mass index (BMI) were obtained at baseline and weeks 4 and 8. Both between-group (Wilcoxon rank-sum test) and within-group (paired t test) comparisons were used to evaluate treatment effects. After 6 weeks of a diet therapy (National Cholesterol Education Program [NECP] Step I) run-in period, subjects in both groups had similar low-density lipoprotein cholesterol (LDL-C) levels (159 mg/dL v 158 mg/dL). The treated group showed a 7.1% +/- 11.6% reduction by 4 weeks, which was maintained at 8 weeks (7.9% +/- 11.0%). Placebo patients had a slight increase in LDL-C values over the same period (+2.4% +/- 11.7%), for a 10.3% difference between groups. The treatment effect was statistically significant both between groups (P <.001) and within the active-treatment group (P <.001) after the 8-week intervention. Apolipoprotein B (ApoB) levels in a representative subset of the treated group (n = 53) decreased by 20% (P =.004). The fiber blend neither raised triacylglycerol (TG) (P =.95) nor lowered high-density lipoprotein cholesterol (HDL-C) levels (P =.54), and lowered homocysteine (active, 9.8 to 8.7/micromol/L, P =.02; placebo, 9.4 to 9.2 /micromol/L, P =.98). Thus, a significant LDL-C lowering effect, with parallel Apo B reduction, was demonstrated for this fiber/vitamin combination. No adverse changes on TG or HDL-C levels were noted, and folate/B vitamin benefits attributed to homocysteine reduction were preserved. Concurrent administration of fiber and vitamins represents a preventive approach that may reduce the need for concomitant lipid-lowering therapies or serve as an adjunct therapy.

Pilot study of coronary atherosclerotic risk and plaque burden in HIV patients: 'a call for cardiovascular prevention'

BACKGROUND

Highly active antiretroviral therapy (HAART) has dramatically improved the life expectancy of patients with human immunodeficiency virus (HIV) prompting increasing concerns related to chronic management. Suggestions of greater cardiovascular risk, partially related to recently proposed HAART-induced dyslipidemia and glucose intolerance, amplify these concerns. At this time, further corroboration of the emerging evidence for increased coronary risk, as well as complimentary estimates of coronary artery atherosclerotic burden, would be valuable to practicing physicians.

METHODS

Seventeen HIV patients on HAART (all from the same HIV clinic population) without coronary artery disease (CAD) were referred to Preventive Cardiology for treatment of dyslipidemia ('referred group'). Upon entry, they underwent computed tomography (CT) of the coronary arteries. Subsequently, the referred group was matched (1:4) for age, gender and traditional risk to non-HIV non-CAD subjects (matched group, n=68) from the University of Illinois CT database. A serial review of 90 subjects from the original HIV population was sampled to determine general cardiovascular risk.

RESULTS

Thirteen (76%) of the 17 referred patients revealed the presence of coronary calcium compared with 63% in the matched HIV seronegative controls (P=0.18). Log-transformed median calcium score was 2.93+/-2.3 in the referred group versus 1.97+/-2.5 in the matched group (P=0.09). Fifty one percent of the overall population smoked cigarettes, 11% were diabetic (30% diagnosed pre-HAART and 70% post-HAART) and 30% were hypertensive (33% diagnosed pre-HAART and 67% post-HAART).

CONCLUSIONS

In a particularly dyslipidemic subgroup of HIV subjects without known CAD we found evidence for atherosclerosis in three-quarters based on coronary calcium. Further, in this population of HIV patients on HAART, we found an enhanced prevalence of traditional cardiovascular risk. This pilot study encourages the development of preventive strategies in this population.

Elevated fibrinogen and homocysteine levels enhance the risk of mortality in patients from a high-risk preventive cardiology clinic

Fibrinogen (Fib) plays an important role in platelet aggregation and thrombus formation, and homocysteine (tHcy) causes endothelial dysfunction and injury. Therefore, an interaction toward an enhanced risk of thrombotic events and consequent mortality might be expected in patients with both factors elevated. To determine whether patients exposed jointly to high Fib and high tHcy were at increased risk of mortality, we compared them with those with only one or neither risk factors elevated. Prevalence of coronary artery disease (cross-section) and short-term mortality (30+/-14 months) were assessed in 2084 patients with available baseline tHcy and Fib. Upper quartiles were used to define high tHcy (>14.2 micromol/L) and high Fib (>382 mg/dL). Cox models adjusting for Framingham risk score, creatinine, and coronary artery disease status were used to estimate the risk of high tHcy and high Fib and their combinations. Mean age of the patients was 56+/-12 years (35% women) with 71 (3.4%) recorded deaths. Risk-adjusted longitudinal models showed a hazard ratio of 2.14 (P=0.03) for isolated high tHcy, 2.28 (P=0.02) for isolated high Fib, and 3.29 (P<0.001) for both high tHcy and high Fib in comparison with neither risk factor high. Independence of each parameter and lack of synergism was found on longitudinal as well as cross-sectional analyses. Conjoint elevation of Fib and tHcy increased the risk of death by approximately 3-fold in three years. Although no significant interaction between Fib and tHcy was demonstrated, both provided independent information after adjustment for traditional risk factors.

Profiles of hepatic and dysrhythmic cardiovascular events following use of fluoroquinolone antibacterials: experience from large cohorts from the Drug Safety Research Unit Prescription-Event Monitoring database

OBJECTIVE

To investigate how frequently serious dysrhythmic cardiovascular, and hepatotoxic events are reported during routine clinical use of fluoroquinolones (quinolones) in general practice.

DESIGN

Cohorts prescribed quinolones (cohort sizes: ciprofloxacin 11 477; enoxacin 2790; ofloxacin 11 033 and norfloxacin 11 110; mean age in each cohort of 48.6 to 57.0 years) were selected from the Drug Safety Research Unit's Prescription-Event Monitoring (PEM) database. The monitoring periods were November 1988 to January 1989 for ciprofloxacin; April 1989 to January 1991 for enoxacin; May 1991 to December 1991 for ofloxacin and October 1990 to October 1991 for norfloxacin. Data collected over the total PEM surveillance period on selected gastrointestinal events were extracted and reviewed to identify possible hepatic events, together with selected cardiovascular events associated with dysrhythmias. For each quinolone, times to onset of the event and patient-months of observation (denominator values) were calculated. The analysis was based on two observation periods: rate of event during the first 7 days following dispensing of a prescription for each drug (W(1)), and rate of event during the second to sixth week inclusive (W(2)).

RESULTS

Scrutiny of original green forms revealed no evidence of drug-induced hepatic dysfunction within 42 days of drug administration for any of the quinolones monitored. No evidence was found of drug-induced dysrhythmic events associated with enoxacin within 42 days of drug administration. Of the other quinolones, 'atrial fibrillation' was reported most often within 42 days following ciprofloxacin administration, with no change in event rate over that time, crude relative risk (CRR)[W(1)/W(2)] 1.0 [95% confidence interval (CI) 0.02 to 8.92]. Other less serious events associated with dysrhythmia were reported with varying incidence within 42 days of quinolone administration. The crude rate of palpitation did not change significantly over that time for ciprofloxacin, ofloxacin and norfloxacin: CRR 0.83 (95% CI 0.02 to 6.86), 2.00 (95% CI 0.19 to 12.20) and 4.99 (95% CI 0.06 to 391.94), respectively. Syncope and tachycardia were also reported for ofloxacin [CRR 9.99 (95% CI 0.52 to 589.49 for both events)] and ciprofloxacin [1.0 (95% CI 0.02, 8.92)] and 2.50 (95% CI 0.04, 47.96) for syncope and tachycardia, respectively].

CONCLUSION

It cannot be ruled out that some rare hepatic and dysrhythmic events associated with quinolones may be drug related. The primary purpose of PEM is signal generation. Compared with the other quinolones, ciprofloxacin was associated with the highest number of reports of dysrhythmic cardiovascular events occurring within 42 days of administration. This requires further investigation by other types of epidemiological study.

Fibrinogen: associations with cardiovascular events in an outpatient clinic

BACKGROUND

Fibrinogen, known to influence the coagulation process, is an independent risk factor for coronary artery disease (CAD). However, its association with myocardial infarction (MI) and its predictive potential for short-term mortality, in an ongoing clinical practice, has not been characterized.

OBJECTIVES

In a high-risk outpatient practice we sought to demonstrate whether baseline fibrinogen levels related to MI rather than CAD alone, and whether baseline serum fibrinogen levels predicted mortality over a short-term follow-up.

METHODS AND RESULTS

From a total of 2126 patients with baseline fibrinogen measurements (mean age, 56 +/- 12 years, 35% female), 1187 patients with CAD (n = 606 with MI) and 939 patients without CAD were evaluated in an active preventive cardiology unit of a large city hospital. Logistic regression models were used to determine the association of fibrinogen with differing CAD presentations. Fibrinogen quartile showed a significant correlation with CAD both univariately and after adjustment for Framingham risk score (odds ratio [OR] = 1.22, P <.001). Fibrinogen levels were significantly associated with the presence of CAD and history of MI (adjusted OR = 1.25, P =.001). Fibrinogen did not show a significant association to CAD when MI was not considered in the analysis (OR = 1.01, P =.82). In this same clinical cohort, after a mean follow-up of 24 +/- 13 months, 41 patients had died. Consistent with the observed association with MI, fibrinogen quartile showed a graded independent relation to mortality in a cohort of both men and women (hazard ratio = 1.81, P <.001).

CONCLUSIONS

In the clinical setting of an outpatient clinic, fibrinogen was directly associated with the presence of MI and was revealed to be an independent short-term predictor of mortality.

Safety profile of tolterodine as used in general practice in England: results of prescription-event monitoring

BACKGROUND

Unstable bladder symptoms are a common problem in general practice. Drug therapy with anticholinergic drugs is frequently used in the management of this condition. However such drugs are associated with a high incidence of anticholinergic adverse effects. Tolterodine is a competitive anticholinergic agent, selective for the bladder as opposed to the salivary glands.

OBJECTIVE

To monitor the safety of tolterodine as used in general practice patients in England for the treatment of urinary frequency, urgency and incontinence.

DESIGN

Prospective observational cohort study.

PATIENTS AND PARTICIPANTS

14,526 patients [mean age 62.7 (SD 16.4) years; 68.6% female].

METHODS

Patients prescribed tolterodine in general practice, soon after the release of the drug in the UK, were followed up for a minimum of 6 months using the technique of prescription-event monitoring (PEM).

RESULTS

The most common adverse events reported were dry mouth, headache, malaise, constipation, dyspepsia, nausea and vomiting and pain in abdomen. We identified some uncommon events as possible adverse drug reactions--notably hallucinations, tachycardia and palpitations. The prevalence of these events was compared with that in patient cohorts for other drugs on the PEM database. The age- and sex-adjusted relative risk of hallucinations on tolterodine compared with 10 drugs of other therapeutic classes, and with terodiline, another drug indicated for bladder instability, was 4.85 [95% confidence interval (CI) 2.72 to 8.66] and 1.25 (95% CI 0.62 to 2.53), respectively. There was no significant difference for tachycardia/palpitation in this comparison.

CONCLUSIONS

Tolterodine is well tolerated in general practice at the recommended daily dose. Hallucinations, tachycardia and palpitations are infrequently associated with the drug.

Association between myeloperoxidase levels and risk of coronary artery disease

CONTEXT

Myeloperoxidase (MPO), a leukocyte enzyme that promotes oxidation of lipoproteins in atheroma, has been proposed as a possible mediator of atherosclerosis.

OBJECTIVE

To determine the association between MPO levels and prevalence of coronary artery disease (CAD).

DESIGN, SETTING, AND PATIENTS

Case-control study conducted from July to September 2000 in a US tertiary care referral center, including 158 patients with established CAD (cases) and 175 patients without angiographically significant CAD (controls).

MAIN OUTCOME MEASURES

Association of MPO levels per milligram of neutrophil protein (leukocyte-MPO) and MPO levels per milliliter of blood (blood-MPO) with CAD risk.

RESULTS

Leukocyte- and blood-MPO levels were both significantly greater in patients with CAD than in controls (P<.001). In multivariable models adjusting for traditional cardiovascular risk factors, Framingham risk score, and white blood cell counts, MPO levels were significantly associated with presence of CAD, with an OR of 11.9 (95% CI, 5.5-25.5) for the highest vs lowest quartiles of leukocyte-MPO and an OR of 20.4 (95% CI, 8.9-47.2) for the highest vs lowest quartiles of blood-MPO.

CONCLUSIONS

Elevated levels of leukocyte- and blood-MPO are associated with the presence of CAD. These findings support a potential role for MPO as an inflammatory marker in CAD and may have implications for atherosclerosis diagnosis and risk assessment.

Effect of hydroxymethylglutaryl coenzyme a reductase inhibitors on the progression of calcific aortic stenosis

BACKGROUND

Recent studies have supported the hypothesis that calcific aortic stenosis is the product of an active inflammatory process, with similarities to atherosclerosis. We sought to determine whether therapy with hydroxymethylglutaryl coenzyme A reductase inhibitors (statins) might slow the progression of aortic stenosis.

METHODS AND RESULTS

A retrospective study of 174 patients (mean age 68+/-12 years) with mild to moderate calcific aortic stenosis was conducted. Patients required normal left ventricular function, </=2+ aortic regurgitation, and >/=2 echocardiograms performed at least 12 months apart. Fifty-seven patients (33%) received treatment with a statin; the remaining 117 (67%) did not. The statin group was older and had a higher prevalence of hypertension, diabetes mellitus, and coronary disease. During a mean follow-up of 21 months, patients treated with statin had a smaller increase in peak and mean gradient and a smaller decrease in aortic valve area. When annualized, the decrease in aortic valve area for the nonstatin group was 0.11+/-0.18 cm(2) compared with 0.06+/-0.16 cm(2) for those treated with a statin (P=0.03). In multivariate analysis, statin usage was a significant independent predictor of a smaller decrease in valve area (P=0.01) and a lesser increase in peak gradient (P=0.02).

CONCLUSIONS

Statin-treated patients, despite a higher risk profile for progression, had reduced aortic stenosis progression compared with those not treated with a statin. These data provide justification for a prospective randomized trial to substantiate whether statin therapy slows the progression of aortic stenosis.

Adverse effects associated with the use of donepezil in general practice in England

Donepezil is an acetylcholinesterase inhibitor indicated for the symptomatic treatment of mild to moderate Alzheimer's disease. It is reported to have a relatively favourable side-effect profile. We report here on a pharmacovigilance study carried out post-marketing in England. An observational cohort study using the technique of Prescription-Event Monitoring was carried out. Some 1762 patients (mean age 72.9 years; 42% male) were followed up for 6 months minimum. The commonest adverse events were nausea, diarrhoea, malaise, dizziness and insomnia. Aggression, agitation and abnormal dreams were uncommonly associated with the drug. There were no cardiac rhythm disturbances or liver disorders causally associated. The commonest adverse drug reactions are already reported in the product information. Given the relatively small size of this cohort, the signals of abnormal dreams and psychiatric disturbance as possible adverse drug reactions need further investigation in carefully planned studies.

Is there an association between selective serotonin reuptake inhibitors and risk of abnormal bleeding? Results from a cohort study based on prescription event monitoring in England

OBJECTIVE

To investigate whether an association between the use of selective serotonin reuptake inhibitor (SSRI) antidepressants and abnormal bleeding is demonstrated in a large population study.

METHODS

An observational cohort study using cohorts from the Drug Safety Research Unit's prescription event monitoring database was performed.

RESULTS

Analysis of combined haemorrhagic event rates calculated for the first 6 months of treatment for four SSRIs showed no significant difference between the rate for abnormal bleeding in the first month after starting treatment compared with months 2-6 [difference in rates 0.63 per 1000 patient months of treatment, 99% confidence interval (CI) -0.4, 1.67]. Comparison of the rates for the exposed combined SSRI cohort with the unexposed non-psychiatric drug cohort for the first month [relative risk (RR) 1.38, 95% CI 0.82, 2.34] and months 2-6 (RR 1.17, 95% CI 0.81, 1.68) showed no significant differences after adjustment for age and gender. However, there was a tendency towards highest risk with the combined SSRI cohort and lowest with the baseline cohort.

CONCLUSION

This study provides weak evidence to support the hypothesis of a link between SSRIs and precipitation of bleeding events at a population level. The 95% CI is consistent with a possible risk of bleeding associated with SSRI users versus non-psychiatric drug users in the first month. Fuller consideration of confounding would be possible using follow-up of identified cases in a nested case-control study.

Comparison of cardiovascular risk and lipid profiles in patients undergoing aortic valve surgery versus those undergoing coronary artery bypass grafting

BACKGROUND AND AIM OF THE STUDY

Hyperlipidemia is a risk factor for the progression of coronary artery disease, and possibly also valvular aortic stenosis. Thus, patients with aortic stenosis, coronary disease (or both) might be expected to have more abnormal lipid profiles than those without these two conditions.

METHODS

The lipid profiles of patient subsets undergoing aortic valve replacement (AVR) with or without concomitant coronary artery bypass grafting (CABG), as well as those undergoing isolated CABG, between 1987 and 1997 were analyzed retrospectively. Four surgical groups were identified: AVR for aortic regurgitation (n = 370); AVR for predominant aortic stenosis (n = 1,072); AVR for aortic stenosis (AS) with CABG (n = 914); and isolated CABG (n = 11,156). The complete fasting lipid profiles of patients were collected, analyzed by group, and compared.

RESULTS

Analysis by Spearman's correlation showed that total cholesterol levels, triglycerides and low-density lipoproteins (LDL-C) were modestly, yet significantly, increased in each successive group, while high-density lipoproteins were decreased. AS patients undergoing isolated AVR had significantly higher total cholesterol (215 versus 201 mg/dl; p <0.0001), triglycerides (125 versus 104 mg/dl; p <0.0001) and LDL-C (139 versus 132 mg/dl; p = 0.003) than those undergoing AVR for aortic regurgitation. Total cholesterol >200 mg/dl was significantly associated with AS, even after adjusting for differences in age, sex, diabetes mellitus and hypertension, with an odds ratio of 1.5 (95% confidence interval, 1.2-2.0; p = 0.001).

CONCLUSION

Progressively abnormal lipid profiles are associated with AS and coronary disease in patients undergoing AVR. This evidence helps to extend the link between dyslipidemia and AS in a large consecutive series of patients.

Lipoprotein(a) associated with coronary artery disease in older women: age and gender analysis

BACKGROUND

Lipoprotein (a) has been associated with increased coronary artery disease (CAD) risk in men, but relatively little data exists in women. While age influences the cardiovascular risk associated with Lp(a) in men, little is known about this phenomenon in women. The impact of gender on Lp(a) has not been fully studied in an ongoing clinical practice.

METHODS AND RESULTS

Baseline Lp(a) values were measured in 918 CAD and 829 non-CAD patients (603 females, 1144 males) entering an outpatient prevention clinic. The age-specific association of elevated Lp(a) (> 30 mg/dl) with CAD was examined after adjustment for traditional risk factors. Lp(a) was a significant risk factor (OR = 1.9, CI, 1.4-2.6) in men and women (OR = 1.9, CI 1.3-2.9). In men age < or = 55 years the odds ratio for increased cardiovascular risk in high vs low Lp(a) was 2.5 (CI 1.6-3.9). In men < or = 55, CAD increased from 32 to 61% as Lp(a) progressively rose from < or = 5 to > or = 45 mg/dl (P value for trend < 0.001). No significant increase was observed in men > 55 years (OR = 1.3, CI 0.9-2.1). In women < or = 55 years, the risk of CAD increased from 22 to 35% (OR 1.6, CI 0.8-3.2), and increased from 38 to 63% in women > 55 (OR 2.1, CI 1.3-3.5). Further, of high-risk patients (men < or = 55 and women > 55 years) with an Lp(a) in the range of 20-44 mg/dl (third quartile), younger men showed a greater incidence of CAD (51%) than older women (43%). Both genders revealed substantial risk when the Lp(a) values were above 45 mg/dl. (OR = 3.7, CI = 2.0-6.8 in younger men; OR = 3.3, CI = 1.6-6.6 in older women).

CONCLUSIONS

In this cross sectional study of both men and women, elevated Lp(a) was associated with a significantly increased risk of CAD in men and women. While we corroborate previous reports on the lack of association in older men, the determination of an enhanced Lp(a)-related risk in older women was new and unanticipated. Further, in this population of high risk patients, substantial cardiovascular risk appeared to be represented by higher concentrations of Lp(a) in women than observed in men.

HDL cholesterol level predicts survival in men after coronary artery bypass graft surgery: 20-year experience from The Cleveland Clinic Foundation

BACKGROUND

HDL cholesterol (HDL-C) is an important independent predictor of atherosclerosis, yet the role that HDL-C may play in the prediction of long-term survival after CABG remains unclear. The risk associated with a low HDL-C level in post-CABG men has not been delineated in relation to traditional surgical variables such as the use of arterial conduits, left ventricular function, and extent of disease.

METHODS AND RESULTS

We performed a prospective, observational study of 432 men who underwent CABG between 1978 and 1979 in whom preoperative HDL-C values were available. Baseline lipid and lipoprotein values, history of diabetes mellitus and hypertension, left ventricular ejection fraction, extent of disease, and use of internal thoracic arteries were recorded. Hazard ratios (HRs) were determined in the patients with and without a low HDL-C level, which was defined as the lowest HDL-C quartile (HDL-C </=35 mg/dL). After adjustment for age, as well as for baseline metabolic parameters and surgical variables just noted, HDL-C corresponded to both overall (HR 0.40, CI 0.20 to 0.83, P:=0.01) and event-free (HR 0.41, CI 0.24 to 0.70, P:=0.001) survival. Patients with a high HDL-C level (>35 mg/dL) were 50% more likely to survive at 15 years than were patients with low HDL-C level (</=35 mg/dL) (74% versus 57% adjusted survival, respectively; HR 1.72, P:=0.005). In addition, HDL-C showed a strong effect on time-to-event survival such that patients with an HDL-C level of >35 mg/dL were 50% more likely to survive without a subsequent myocardial infarction or revascularization (HR 1.42, P:=0.02).

CONCLUSIONS

HDL-C is an important predictor of survival in post-CABG patients. In this study of >8500 patient-years of follow-up, HDL-C was the most important metabolic predictor of post-CABG survival. One third fewer patients survive at 15 years if their HDL-C levels are </=35 mg/dL at the time of CABG. The measurement of HDL-C provides a compelling strategy for the identification of high-risk subsets of patients who undergo CABG.

HDL Cholesterol Level Predicts Survival in Men After Coronary Artery Bypass Graft Surgery

Background —HDL cholesterol (HDL-C) is an important independent predictor of atherosclerosis, yet the role that HDL-C may play in the prediction of long-term survival after CABG remains unclear. The risk associated with a low HDL-C level in post-CABG men has not been delineated in relation to traditional surgical variables such as the use of arterial conduits, left ventricular function, and extent of disease.

Methods and Results —We performed a prospective, observational study of 432 men who underwent CABG between 1978 and 1979 in whom preoperative HDL-C values were available. Baseline lipid and lipoprotein values, history of diabetes mellitus and hypertension, left ventricular ejection fraction, extent of disease, and use of internal thoracic arteries were recorded. Hazard ratios (HRs) were determined in the patients with and without a low HDL-C level, which was defined as the lowest HDL-C quartile (HDL-C ≤35 mg/dL). After adjustment for age, as well as for baseline metabolic parameters and surgical variables just noted, HDL-C corresponded to both overall (HR 0.40, CI 0.20 to 0.83, P =0.01) and event-free (HR 0.41, CI 0.24 to 0.70, P =0.001) survival. Patients with a high HDL-C level (>35 mg/dL) were 50% more likely to survive at 15 years than were patients with low HDL-C level (≤35 mg/dL) (74% versus 57% adjusted survival, respectively; HR 1.72, P =0.005). In addition, HDL-C showed a strong effect on time-to-event survival such that patients with an HDL-C level of >35 mg/dL were 50% more likely to survive without a subsequent myocardial infarction or revascularization (HR 1.42, P =0.02).

Conclusions —HDL-C is an important predictor of survival in post-CABG patients. In this study of >8500 patient-years of follow-up, HDL-C was the most important metabolic predictor of post-CABG survival. One third fewer patients survive at 15 years if their HDL-C levels are ≤35 mg/dL at the time of CABG. The measurement of HDL-C provides a compelling strategy for the identification of high-risk subsets of patients who undergo CABG.

Preoperative triglycerides predict post-coronary artery bypass graft survival in diabetic patients: a sex analysis

OBJECTIVE

Hypertriglyceridemia is commonly observed in association with diabetes. Despite cross-sectional studies and isolated longitudinal analyses in patients without coronary artery disease, the suggestion that triglyceride levels are relevant to subsequent cardiovascular events in the setting of diabetes remains controversial. This study evaluates the predictive value of serum triglyceride levels on mortality in post-coronary artery bypass graft (CABG) diabetic patients with subsequent analysis by sex.

RESEARCH DESIGN AND METHODS

This longitudinal observational study involving a large metropolitan hospital consists of 1,172 diabetic post-CABG patients (792 men and 380 women) with lipid data collected between the years 1982 and 1992. Cox proportional hazards regression models were used to estimate the risk of mortality and cardiac events associated with triglyceride levels in the highest quartile (> 2.90 mmol/l for men and > 3.12 mmol/l for women).

RESULTS

Elevated preoperative serum triglyceride values in post-CABG subjects with diabetes were correlated with increased overall mortality (hazard ratio [HR] 1.26, 95% CI 1.00-1.59). The greatest influence of triglyceride levels was observed on overall (1.89, 1.30-2.73) and event-free survival (1.49, 1.06-2.08) in women. High triglyceride values were also modestly related to risk of cardiac events in diabetic men (1.28, 0.99-1.66).

CONCLUSIONS

These data suggest that increased preoperative triglyceride levels predict increased late mortality and cardiac event risk in diabetic post-CABG patients, more strongly in women than in men.

Front line workers in long-term care: the effect of educational interventions and stabilization of staffing ratios on turnover and absenteeism

OBJECTIVE

Front line workers in long-term care play a crucial role in helping residents achieve their highest possible functional level. High turnover (rates in excess of 100% are common) and absenteeism threaten the ability of long-term care providers to meet this goal. The purpose of this study was to determine the effect of a formalized certified nursing assistant (CNA) education program and stabilization of staffing ratios on turnover and absenteeism.

DESIGN AND SETTING

This study was a 12-month prospective, nonrandomized trial involving two long-term care facilities providing traditional intermediate and skilled care serving as study sites and a similar facility serving as a control. For historical comparisons, each facility served as its own control using data from the year before the interventions.

INTERVENTIONS

An in-house educational program based on the State of North Carolina core curriculum for CNAs was instituted in each study site. During the study period, efforts were made to achieve stable staffing ratios of 1 CNA:8 residents for days, 1:10 for evenings, and 1:15 for nights. Traditional quality of care indicators and resident/surrogate satisfaction were tracked during the study period.

RESULTS

Both study facilities showed a decline in turnover, with the decline reaching statistically significant levels at Facility B (134% to 41%, P = 0.0001). Absenteeism rates did not change significantly during the study period. Resident/surrogate satisfaction with nursing care was improved significantly at Facility B (P = 0.02).

CONCLUSION

A formal education program in conjunction with stabilization of staffing ratios can result in lower turnover rates for CNA's and improved resident/surrogate satisfaction.

How deadly is the "deadly quartet"? A post-CABG evaluation

OBJECTIVES

The aim of the study was to determine the value of a cluster of metabolic risk factors in predicting mortality after coronary artery bypass surgery (CABG).

BACKGROUND

The "deadly quartet" of metabolic risk factors (i.e., obesity, diabetes, hypertension, and hypertriglyceridemia) has been associated with coronary heart disease in healthy population studies. The expected influence of the cluster on survival in secondary prevention remains untested overall as well as by gender.

METHODS

Patients with lipid profiles undergoing primary isolated CABG (n = 6,428) between 1987 and 1992 were followed a median of eight years. Cox models were used to evaluate all-cause mortality. Metabolic risk factors were incorporated as the sum of deadly quartet risk factors present in each patient (0 to 4). The role of gender as it relates to survival and metabolic risk clusters was also examined.

RESULTS

The sum of deadly quartet risk factors showed a significant relationship to mortality as the hazard ratio increased from 1.64 (confidence interval [CI] = 1.34-2.01) for one risk factor to 3.95 (2.73-5.69) for four risk factors. Annualized mortality ranged from 1% per year in patients with no risk factors to 3.3% per year in patients with all four risk factors. Within gender, the hazard ratio associated with four risk factors was 2.58 for men and 13.39 for women. The expected clustering of risk factors was 8% compared to the observed clustering of 10% in men and 21% in women.

CONCLUSIONS

This cohort showed risk factor clustering beyond that expected due to chance, particularly in women. Even after revascularization, survival is diminished for patients with members of a family of metabolic risk factors at the time of surgery.

Relation of serum triglyceride levels to survival after coronary artery bypass grafting

We performed a prospective observational study on 6,602 subjects (94% for 5 years and 34% for 10 to 15 years) who underwent coronary artery bypass graft surgery (CABG) between 1982 and 1992. We examined whether triglyceride concentrations adjusted for other factors (total cholesterol, history of diabetes mellitus, systemic hypertension, left ventricular function, number of coronary arteries significantly narrowed, and use of the internal thoracic arteries) explained total and event-free survival. These analyses were duplicated within gender (1,354 women and 5,248 men). This approach allowed a determination of any gender-related disparities in lipid predictors. Triglycerides in the highest quartile were associated with an increased risk of mortality of 20% (confidence interval [CI] 1.0 to 1.4). Similar risk was seen for event-free survival. Although there was no evidence of gender differences in adjusted survival (p = 0.33), a gender by triglyceride interaction (p = 0.004) indicated that the response to high triglycerides as related to survival did differ by gender. Specifically, women had a dramatically higher risk (hazard ratio [HR] 1.5, CI 1.1 to 2.1) than men (HR 1.1, CI 0.9 to 1. 3). Both men and women did have triglyceride-associated risk with regard to event-free survival (HR in men 1.2, CI 1.1 to 1.4; HR in women 1.4, CI 1.1 to 1.8). Examination of high-density lipoprotein cholesterol in a subcohort did not eliminate the observed triglyceride effects. Thus, triglyceride baseline values are primary determinants (similar to baseline left ventricular function or extent of coronary disease) for long-term total and event-free mortality after CABG in women but not in men.

Sedation with "non-sedating" antihistamines: four prescription-event monitoring studies in general practice

OBJECTIVES

To investigate the frequency with which sedation was reported in post-marketing surveillance studies of four second generation antihistamines: loratadine, cetirizine, fexofenadine, and acrivastine.

DESIGN

Prescription-event monitoring studies.

SETTING

Prescriptions were obtained for each cohort in the immediate post-marketing period.

SUBJECTS

Event data were obtained for a total of 43 363 patients.

MAIN OUTCOME MEASURES

Reporting of sedation or drowsiness.

RESULTS

The odds ratios (adjusted for age and sex) for the incidence of sedation were 0.63 (95% confidence interval 0.36 to 1.11; P=0.1) for fexofenadine; 2.79 (1.69 to 4.58; P<0.0001) for acrivastine, and 3.53 (2.07 to 5.42; P<0.0001) for cetirizine compared with loratadine. No increased risk of accident or injury was evident with any of the four drugs.

CONCLUSIONS

Although the risk of sedation was low with all four drugs, fexofenadine and loratadine may be more appropriate for people working in safety critical jobs.

Homocysteine and lipoprotein(a) interact to increase CAD risk in young men and women

A biochemical link between homocysteine (tHcy) and lipoprotein(a) [Lp(a)] related to fibrin binding has been proposed. This hypothesis has not been specifically examined in human subjects. We sought to determine in a clinical setting whether these risk factors would interact to increase coronary artery disease (CAD) risk. We performed a cross-sectional analysis of 750 men and 403 women referred to a preventive cardiology clinic at the Cleveland Clinic Foundation, in whom baseline tHcy and Lp(a) data were available. Logistic regression after adjusting for standard cardiovascular risk factors was used to estimate the relative risk of CAD in patients with an Lp(a) >/=30 mg/dL and a tHcy >/=17 micromol/L. Neither isolated high tHcy (odds ratio [OR]=1.06, P=0.89) nor isolated high Lp(a) (OR=1.15, P=0.60) appeared to be associated with CAD in women. However, strong evidence of an association was seen when both risk factors were present (OR=4.83, P=0.003). Moreover, this increased risk showed evidence of an interactive effect beyond that attributable to either additive or multiplicative effects of tHcy and Lp(a) (P=0.03). In contrast, both elevated tHcy (OR=1.93, P=0. 05) and elevated Lp(a) (OR=1.87, P=0.01) showed evidence of being independent risk factors for CAD in men. The presence of both risk factors in men did not appear to confer additional risk (OR=2.00, P=0.09), even though ORs as high as 12.4 were observed within specific age intervals. Consistent with prior studies, tHcy and Lp(a) are risk factors, either independently or in concert, for CAD in this clinical population. More significantly, we found evidence that when both risk factors were present in women, the associated risk was greater than what would be expected if the 2 risks were simply acting independently. The absence of such an interactive effect in men may be due to the confounding effects of age manifested as "survivor bias." These clinical findings provide insights into the potential roles of both tHcy and Lp(a) in the pathogenesis of atherosclerosis.