Title: Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease
Topic: Prevention/Vascular
Date Posted: 2/4/2010
Author(s): Hayward RA, Krumholz HM, Zulman DM, Timble JW, Vijan S.
Citation: Ann Intern Med 2010;152:69-77.
Clinical Trial: No
Study Question: Would a tailored treatment approach compare favorably to a treat-to-target approach for primary prevention of coronary artery disease (CAD)?
Methods: A simulated model of population-level effects was used to compare treat-to-target and tailored treatment approaches to statin therapy. Data sources included statin trials from 1994 to 2009 and nationally representative CAD risk factor data. The target population was U.S. persons ages 30-75 years with no history of myocardial infarction. Tailored treatment was based on a person’s 5-year CAD risk (simvastatin, 40 mg, for 5-15% CAD risk; and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program (NCEP) III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria). Outcomes included lifetime effects of 5 years of treatment, as measured by quality-adjusted life-years (QALYs) from a societal and patient perspective.
Results: The standard NCEP III treat-to-target approach would recommend that 37.9 million U.S. persons should receive statins, of which 7.9 million should receive high dose–potency therapy. Compared with no treatment, the standard NCEP III approach was estimated to save 48 QALYs per 1,000 persons treated for 5 years, resulting in about 1.83 million total QALYs saved in the United States. Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins. No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.
Conclusions: A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol–based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.
Perspective: I suspect there are two patterns of statin use in the United States. One group of physicians and their patients underuse and underdose, and the other is aggressive, sometimes overtreating, but usually appropriate dosing in patients at high risk. Very few actually use the guidelines. The approach suggested by Rod Hayward may underestimate the value of a tailored but simple treatment strategy, which might be benefited by further risk stratification with a coronary calcium score in middle-aged and older men and women. Melvyn Rubenfire, M.D., F.A.C.C.
Title: Fulminant Myocarditis Associated With Pandemic H1N1 Influenza A Virus in Children
Topic: Heart Failure/Transplant
Date Posted: 2/10/2010 5:00:00 PM
Author(s): Bratincsak A, El-Said HG, Bradley JS, Shayan K, Grossfeld PD, Cannavino CR.
Citation: J Am Coll Cardiol 2010;Feb 10:[Epub ahead of print].
Clinical Trial: No
Study Question: Is fulminant myocarditis associated with pandemic H1N1 influenza A virus in children?
Perspective: Acute myocarditis is a well-described manifestation of numerous viral infections, and may present with a broad spectrum of symptoms and clinical features. Fulminant myocarditis is thought to be rarely associated with influenza A and may present with fatal arrhythmias, high grade atrioventricular block, and even cardiogenic shock. The true prevalence of influenza-associated fulminant myocarditis is not known because of the lack of comprehensive screening, with only a few cases reported in the literature. The four documented cases of myocarditis in the current study, and other prior reports, raise the concern that the novel H1N1 influenza A virus may be more commonly associated with a severe form of myocarditis than previously seen influenza strains. These observations warrant a high index of clinical suspicion for myocarditis in children with H1N1 influenza A infection. Early diagnosis and rapid intervention with circulatory support may decrease morbidity and mortality, with the potential for saving myocardium and lives. Debabrata Mukherjee, M.D., F.A.C.C.
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