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Only doctors can save America
Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:
Only you can save America.
He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.
"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.
If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."
Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.
Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.
Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.
The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.
Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.
Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.
Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.
Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.
In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.
"You have to lead this," he explained.
No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.
Dr. Emanuel reported having no financial disclosures.
Twitter: @sherryboschert
Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:
Only you can save America.
He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.
"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.
If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."
Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.
Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.
Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.
The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.
Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.
Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.
Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.
Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.
In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.
"You have to lead this," he explained.
No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.
Dr. Emanuel reported having no financial disclosures.
Twitter: @sherryboschert
Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:
Only you can save America.
He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.
"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.
If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."
Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.
Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.
Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.
The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.
Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.
Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.
Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.
Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.
In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.
"You have to lead this," he explained.
No one should expect that reforming the fifth-largest economy in the world could be accomplished in just a few years, however. "It's going to take this decade," Dr. Emanuel predicted.
Dr. Emanuel reported having no financial disclosures.
Twitter: @sherryboschert
Practical support helps teens get active
Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.
On Twitter @sherryboschert
Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.
On Twitter @sherryboschert
Earn 0.25 hours AMA PRA Category 1 credit: Read this article, and click the link at the end to take the post-test.
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
To earn 0.25 hours AMA PRA Category 1 credit after reading this article, take the post-test here.
On Twitter @sherryboschert
AT THE ANNUAL MEETING OF THE SOCIETY OF BEHAVIORAL MEDICINE
Practical support helps teens get active
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Families who want to help their adolescents become physically active should focus on logistical assistance more than emotional support, a study of 1,422 sixth graders has shown.
Emotional support from peers was associated with an increased likelihood of moderate to vigorous physical activity, but not emotional support from families. Families did make a difference, however, by providing instrumental support such as transportation and sports equipment, E. Rebekah Siceloff, Ph.D., and her associates reported at the annual meeting of the Society of Behavioral Medicine.
They conducted a secondary analysis of data on 1,422 sixth graders from 24 middle schools in the Activity by Choice Today trial, which primarily studied a separate intervention aimed at increasing physical activity in predominantly racial minority students from low socioeconomic status families.
The current analysis looked at what kinds of social support mattered for increasing physical activity. At baseline, moderate to vigorous physical activity was significantly associated with peer emotional support and with family instrumental support. High levels of family emotional support did not translate into higher activity levels at baseline.
Six months later, only family instrumental support predicted an increase in moderate to vigorous physical activity over time. Both the baseline family instrumental support and increases in family instrumental support during those 6 months were associated with increased moderate to vigorous physical activity, said Dr. Siceloff, a postdoctoral fellow in the psychology department at the University of South Carolina, Columbia.
"Parents may be especially crucial and families may be especially crucial for getting [adolescents] to places and providing opportunities to be physically active," she said. The findings are consistent with some previous qualitative research showing that instrumental support for physical activity may be especially important for underserved youths. Adolescents often perceive emotional support to be controlling, not supportive, she said.
Her study won a citation for the best of her session at the meeting.
The youths in the study had a mean age of 11 years. Fifty-four percent were girls, 73% were African American, and 72% qualified for free or reduced-cost lunches. The mean body mass index was 23 kg/m2; 51% of the participants were in the 85th percentile for being overweight or obese.
"It’s really imperative that we consider the type of family social support," she said. "It’s the instrumental support that’s really important," particularly in populations of underserved youths. When families with few resources are unable to provide the instrumental support that adolescents need to be active, increased community support is essential, she added.
Families may find it hard to provide instrumental support because they lack money, time, a car or good public transportation, and equipment for physical activity, and because neighborhood crime makes the streets unsafe.
The study used six-item scales to assess family and peer emotional support and a four-item scale to assess family instrumental support. Adolescent physical activity was assessed using accelerometers.
The investigators previously reported that the main intervention in the study – a 17-week after-school program – increased activity during the program but not outside of it (Health Psychol. 2011;30:463-71).
Dr. Siceloff reported having no relevant financial disclosures.
On Twitter @sherryboschert
AT THE ANNUAL MEETING OF THE SOCIETY OF BEHAVIORAL MEDICINE
Major finding: Family instrumental support, not emotional support, was significantly associated with moderate to vigorous activity in adolescents.
Data source: A secondary analysis of data on 1,422 sixth graders in a trial of a separate intervention aimed at increasing their physical activity.
Disclosures: Dr. Siceloff reported having no relevant financial disclosures.
Lipid levels vary seasonally
SAN FRANCISCO – Cholesterol levels fluctuated significantly by season in a prospective study of 227,359 Brazilians.
Compared with lipid levels in the summer, in the winter the mean plasma LDL cholesterol level increased by 7 mg/dL, resulting in an 8% increase in the prevalence of high LDL cholesterol (>130 mg/dL) in the winter, Dr. Filipe A. Moura and his associates reported at the annual meeting of the American College of Cardiology.
The variations are pronounced enough that clinicians may want to keep a closer eye on patients who are borderline hypercholesterolemic in the summer months, because they may be at higher risk than expected once winter comes, said Dr. Moura, a doctoral candidate at the State University of Campinas, Brazil. He and his associates plan to study patients who present with an MI to see if lipid profiles at presentation vary seasonally in a similar fashion.
The current cross-sectional study prospectively compared lipid levels in patients seen for health checkups in five primary care centers in Campinas from 2008 to 2010. The variations between maximum and minimum lipid levels reached 7 mg/dL for LDL cholesterol, 3 mg/dL for HDL, and 12 mg/dL for triglycerides.
Even greater variations might be seen in nontropical countries that experience more extreme climate changes between seasons, such as the United States or Europe, Dr. Moura speculated. Campinas has mild, dry winters and is located at 1,821-2,559 feet above sea level.
Other lipid levels varied as well. Mean HDL cholesterol levels below 40 mg/dL were 9% more prevalent in summer than in winter, and mean triglyceride levels higher than 150 mg/dL were 5% more prevalent in summer than in winter,
Previous, smaller studies had suggested that there might be seasonal variations in LDL cholesterol. Those studies did not find the increased rates of low HDL and high triglycerides in summer seen in the current study, perhaps because they were not done in tropical climates, he said.
The current study found more pronounced seasonal lipid changes in women and middle-aged adults, but this is likely due to larger sample sizes in these subgroups, Dr. Moura said. Patients ranged in age from less than 1 year to 110 years old, and 64% were female.
Besides the seasonal climate changes, seasonal behavior changes may have affected lipid levels, he speculated. In winter, people tend to exercise less and eat more food in general and fattier foods in particular. Less exposure to sunshine in winter may lower serum concentrations of vitamin D, and vitamin D status has been associated with the ratio of bad to good cholesterol.
Dr. Moura reported having no financial disclosures.
Twitter: @sherryboschert
SAN FRANCISCO – Cholesterol levels fluctuated significantly by season in a prospective study of 227,359 Brazilians.
Compared with lipid levels in the summer, in the winter the mean plasma LDL cholesterol level increased by 7 mg/dL, resulting in an 8% increase in the prevalence of high LDL cholesterol (>130 mg/dL) in the winter, Dr. Filipe A. Moura and his associates reported at the annual meeting of the American College of Cardiology.
The variations are pronounced enough that clinicians may want to keep a closer eye on patients who are borderline hypercholesterolemic in the summer months, because they may be at higher risk than expected once winter comes, said Dr. Moura, a doctoral candidate at the State University of Campinas, Brazil. He and his associates plan to study patients who present with an MI to see if lipid profiles at presentation vary seasonally in a similar fashion.
The current cross-sectional study prospectively compared lipid levels in patients seen for health checkups in five primary care centers in Campinas from 2008 to 2010. The variations between maximum and minimum lipid levels reached 7 mg/dL for LDL cholesterol, 3 mg/dL for HDL, and 12 mg/dL for triglycerides.
Even greater variations might be seen in nontropical countries that experience more extreme climate changes between seasons, such as the United States or Europe, Dr. Moura speculated. Campinas has mild, dry winters and is located at 1,821-2,559 feet above sea level.
Other lipid levels varied as well. Mean HDL cholesterol levels below 40 mg/dL were 9% more prevalent in summer than in winter, and mean triglyceride levels higher than 150 mg/dL were 5% more prevalent in summer than in winter,
Previous, smaller studies had suggested that there might be seasonal variations in LDL cholesterol. Those studies did not find the increased rates of low HDL and high triglycerides in summer seen in the current study, perhaps because they were not done in tropical climates, he said.
The current study found more pronounced seasonal lipid changes in women and middle-aged adults, but this is likely due to larger sample sizes in these subgroups, Dr. Moura said. Patients ranged in age from less than 1 year to 110 years old, and 64% were female.
Besides the seasonal climate changes, seasonal behavior changes may have affected lipid levels, he speculated. In winter, people tend to exercise less and eat more food in general and fattier foods in particular. Less exposure to sunshine in winter may lower serum concentrations of vitamin D, and vitamin D status has been associated with the ratio of bad to good cholesterol.
Dr. Moura reported having no financial disclosures.
Twitter: @sherryboschert
SAN FRANCISCO – Cholesterol levels fluctuated significantly by season in a prospective study of 227,359 Brazilians.
Compared with lipid levels in the summer, in the winter the mean plasma LDL cholesterol level increased by 7 mg/dL, resulting in an 8% increase in the prevalence of high LDL cholesterol (>130 mg/dL) in the winter, Dr. Filipe A. Moura and his associates reported at the annual meeting of the American College of Cardiology.
The variations are pronounced enough that clinicians may want to keep a closer eye on patients who are borderline hypercholesterolemic in the summer months, because they may be at higher risk than expected once winter comes, said Dr. Moura, a doctoral candidate at the State University of Campinas, Brazil. He and his associates plan to study patients who present with an MI to see if lipid profiles at presentation vary seasonally in a similar fashion.
The current cross-sectional study prospectively compared lipid levels in patients seen for health checkups in five primary care centers in Campinas from 2008 to 2010. The variations between maximum and minimum lipid levels reached 7 mg/dL for LDL cholesterol, 3 mg/dL for HDL, and 12 mg/dL for triglycerides.
Even greater variations might be seen in nontropical countries that experience more extreme climate changes between seasons, such as the United States or Europe, Dr. Moura speculated. Campinas has mild, dry winters and is located at 1,821-2,559 feet above sea level.
Other lipid levels varied as well. Mean HDL cholesterol levels below 40 mg/dL were 9% more prevalent in summer than in winter, and mean triglyceride levels higher than 150 mg/dL were 5% more prevalent in summer than in winter,
Previous, smaller studies had suggested that there might be seasonal variations in LDL cholesterol. Those studies did not find the increased rates of low HDL and high triglycerides in summer seen in the current study, perhaps because they were not done in tropical climates, he said.
The current study found more pronounced seasonal lipid changes in women and middle-aged adults, but this is likely due to larger sample sizes in these subgroups, Dr. Moura said. Patients ranged in age from less than 1 year to 110 years old, and 64% were female.
Besides the seasonal climate changes, seasonal behavior changes may have affected lipid levels, he speculated. In winter, people tend to exercise less and eat more food in general and fattier foods in particular. Less exposure to sunshine in winter may lower serum concentrations of vitamin D, and vitamin D status has been associated with the ratio of bad to good cholesterol.
Dr. Moura reported having no financial disclosures.
Twitter: @sherryboschert
AT ACC 13
Major finding: Mean LDL levels were 7 mg/dL higher, for an 8% increase in prevalence of high LDL (greater than130 mg/dL), in winter compared with summer.
Data source: Prospective cross-sectional study of lipid measurements in 227,359 Brazilians during 2008-2010.
Disclosures: Dr. Moura reported having no financial disclosures.
Tailored online feedback may boost asthma control
SAN FRANCISCO – A website designed to give people with asthma tailored feedback about whether they need to see a doctor and what questions to ask when they do may have helped improve asthma control in a randomized, controlled trial in 325 patients.
The study randomized patients to get access to one of two modules in a "patient activation website." The asthma module provided tailored feedback about patients’ asthma control, helped them decide whether they needed to visit a medical provider sooner than already scheduled, and suggested questions for patients to ask their providers. The control group got access to a module that suggested questions they should ask their primary care providers about preventive services such as cancer screening.
Among 325 adults who completed 12 months of follow-up (157 in the intervention group and 168 in the control group), measures of asthma control improved significantly in both groups, with most measures improving significantly more in the intervention group compared with the control group.
Mean scores on the Asthma Control Test (ACT) increased from 17.7 at baseline to 19.9 at 12 months in the intervention group and from 17.9 to 19.1 in the control group, both of which were significant improvements. The greater improvement in the intervention group was statistically significant compared with the control group, Jennifer M. Poger and her associates reported in a poster presentation at the annual meeting of the Society of Behavioral Medicine.
The proportions of patients with controlled asthma (defined as an ACT score of 20 or greater) increased from 50% at baseline to 73% at 12 months in the intervention group and from 53% to 67% in the control group, both of which were statistically significant improvements. The difference between groups, however, did not reach statistical significance, reported Ms. Poger, a researcher at Pennsylvania State University, Hershey, Penn.
The mean number of inhaled asthma medications being used increased by 0.4 in the intervention group between baseline and the 12-month follow-up, compared with 0.2 more medications in the control group, a statistically significant difference between groups.
The results suggest that websites that provide tailored feedback to patients with chronic conditions such as asthma may help them control their diseases, Ms. Poger said.
The investigators’ financial disclosures were not available.
SAN FRANCISCO – A website designed to give people with asthma tailored feedback about whether they need to see a doctor and what questions to ask when they do may have helped improve asthma control in a randomized, controlled trial in 325 patients.
The study randomized patients to get access to one of two modules in a "patient activation website." The asthma module provided tailored feedback about patients’ asthma control, helped them decide whether they needed to visit a medical provider sooner than already scheduled, and suggested questions for patients to ask their providers. The control group got access to a module that suggested questions they should ask their primary care providers about preventive services such as cancer screening.
Among 325 adults who completed 12 months of follow-up (157 in the intervention group and 168 in the control group), measures of asthma control improved significantly in both groups, with most measures improving significantly more in the intervention group compared with the control group.
Mean scores on the Asthma Control Test (ACT) increased from 17.7 at baseline to 19.9 at 12 months in the intervention group and from 17.9 to 19.1 in the control group, both of which were significant improvements. The greater improvement in the intervention group was statistically significant compared with the control group, Jennifer M. Poger and her associates reported in a poster presentation at the annual meeting of the Society of Behavioral Medicine.
The proportions of patients with controlled asthma (defined as an ACT score of 20 or greater) increased from 50% at baseline to 73% at 12 months in the intervention group and from 53% to 67% in the control group, both of which were statistically significant improvements. The difference between groups, however, did not reach statistical significance, reported Ms. Poger, a researcher at Pennsylvania State University, Hershey, Penn.
The mean number of inhaled asthma medications being used increased by 0.4 in the intervention group between baseline and the 12-month follow-up, compared with 0.2 more medications in the control group, a statistically significant difference between groups.
The results suggest that websites that provide tailored feedback to patients with chronic conditions such as asthma may help them control their diseases, Ms. Poger said.
The investigators’ financial disclosures were not available.
SAN FRANCISCO – A website designed to give people with asthma tailored feedback about whether they need to see a doctor and what questions to ask when they do may have helped improve asthma control in a randomized, controlled trial in 325 patients.
The study randomized patients to get access to one of two modules in a "patient activation website." The asthma module provided tailored feedback about patients’ asthma control, helped them decide whether they needed to visit a medical provider sooner than already scheduled, and suggested questions for patients to ask their providers. The control group got access to a module that suggested questions they should ask their primary care providers about preventive services such as cancer screening.
Among 325 adults who completed 12 months of follow-up (157 in the intervention group and 168 in the control group), measures of asthma control improved significantly in both groups, with most measures improving significantly more in the intervention group compared with the control group.
Mean scores on the Asthma Control Test (ACT) increased from 17.7 at baseline to 19.9 at 12 months in the intervention group and from 17.9 to 19.1 in the control group, both of which were significant improvements. The greater improvement in the intervention group was statistically significant compared with the control group, Jennifer M. Poger and her associates reported in a poster presentation at the annual meeting of the Society of Behavioral Medicine.
The proportions of patients with controlled asthma (defined as an ACT score of 20 or greater) increased from 50% at baseline to 73% at 12 months in the intervention group and from 53% to 67% in the control group, both of which were statistically significant improvements. The difference between groups, however, did not reach statistical significance, reported Ms. Poger, a researcher at Pennsylvania State University, Hershey, Penn.
The mean number of inhaled asthma medications being used increased by 0.4 in the intervention group between baseline and the 12-month follow-up, compared with 0.2 more medications in the control group, a statistically significant difference between groups.
The results suggest that websites that provide tailored feedback to patients with chronic conditions such as asthma may help them control their diseases, Ms. Poger said.
The investigators’ financial disclosures were not available.
AT THE ANNUAL MEETING OF THE SOCIETY OF BEHAVIORAL MEDICINE
Is same-day discharge after PCI safe?
Is sending patients home the same day they undergo percutaneous coronary intervention as safe as watching patients overnight in the hospital? Dr. Kimberly Brayton discusses the results of a meta-analysis, and outlines her own medical center's protocol for post-PCI discharge.
Is sending patients home the same day they undergo percutaneous coronary intervention as safe as watching patients overnight in the hospital? Dr. Kimberly Brayton discusses the results of a meta-analysis, and outlines her own medical center's protocol for post-PCI discharge.
Is sending patients home the same day they undergo percutaneous coronary intervention as safe as watching patients overnight in the hospital? Dr. Kimberly Brayton discusses the results of a meta-analysis, and outlines her own medical center's protocol for post-PCI discharge.
More insulin resistance, metabolic syndrome with PTSD
SAN FRANCISCO – Posttraumatic stress disorder independently increased the risk of insulin resistance by 80% and metabolic syndrome by 40% in a retrospective study of 207,954 veterans.
The incidence of insulin resistance was 14% higher and the incidence of metabolic syndrome was 12% higher in 11,420 veterans with posttraumatic stress disorder (PTSD), compared with 196,534 without PTSD, after adjusting for the effects of age, gender, ethnicity, high blood pressure, high cholesterol, family history of premature coronary artery disease, and obesity, study coleader Dr. Ramin Ebrahimi reported at the annual meeting of the American College of Cardiology.
Insulin resistance is known to increase atherogenesis and atherosclerotic plaque instability, resulting in greater risk for MI. The cluster of conditions known as metabolic syndrome (hypertension, hyperlipidemia, hyperglycemia, and abnormal cholesterol levels) has been associated with increased risk of heart disease, diabetes, and stroke.
Among veterans with PTSD, 35% had insulin resistance and 53% had metabolic syndrome, compared with 19% and 38%, respectively, in the non-PTSD group before adjusting for other factors, showing relative risk increases of roughly 80% and 40%. PTSD remained independently associated with higher rates of insulin resistance and metabolic syndrome after controlling for other risk factors, said Dr. Ebrahimi of the University of California, Los Angeles.
The investigators analyzed electronic medical records from primary care settings in the Veterans Health Administration for patients in Southern California and Nevada without known diabetes or coronary artery disease who were followed for a median of 2 years.
Although the PTSD and non-PTSD groups were similar at baseline in age, gender, lipid measures, fasting blood sugar measures, and conventional risk factors for insulin resistance and metabolic syndrome, the PTSD group developed significantly higher levels of triglycerides and fasting blood sugar, lower HDL levels, and a higher triglyceride to HDL ratio, compared with the non-PTSD group. At baseline, the veterans had a mean age of 60 years and 93% were male.
The findings may help clinicians identify and treat cardiovascular risks earlier in patients with PTSD, Dr. Ebrahimi suggested at a press conference at the meeting. Early-stage insulin resistance and metabolic syndrome can be reversed with lifestyle modifications in diet and exercise, and a more integrated approach to treating PTSD may be warranted.
The investigators now are studying the relationship of early PTSD treatment and the risk for insulin resistance and metabolic syndrome. They also are examining the effects of combined psychiatric and medical management of PTSD on the risks of metabolic disorders, MI, stroke, and death.
Whether the PTSD itself or something associated with PTSD increases the risks for insulin resistance and metabolic syndrome once PTSD is diagnosed, "these patients must be looked at a little more closely, and the risk factors in general have to be controlled a little bit more vigilantly," said Dr. Ebrahimi, who is also an interventional cardiologist in the Veterans Affairs Greater Los Angeles Healthcare System.
Nearly 8 million U.S. residents have PTSD, which is now recognized to be prevalent not only in veterans but in the broader population. "It happens when you are in an accident or have an experience that confers significant stress, health damage, or death," including rape and other traumatic events, he said.
The study defined insulin resistance as a triglyceride/HDL ratio of 3.8 or greater. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Program III guidelines.
Dr. Ebrahimi disclosed financial relationships with Boehringer Ingelheim, Abbott Vascular, the Medicines Company, Sanofi-Aventis, and Gilead.
*Correction 3/27/2013: An earlier version of this article included different percentages of insulin resistance and metabolic syndrome in the Major Finding section of this page.
SAN FRANCISCO – Posttraumatic stress disorder independently increased the risk of insulin resistance by 80% and metabolic syndrome by 40% in a retrospective study of 207,954 veterans.
The incidence of insulin resistance was 14% higher and the incidence of metabolic syndrome was 12% higher in 11,420 veterans with posttraumatic stress disorder (PTSD), compared with 196,534 without PTSD, after adjusting for the effects of age, gender, ethnicity, high blood pressure, high cholesterol, family history of premature coronary artery disease, and obesity, study coleader Dr. Ramin Ebrahimi reported at the annual meeting of the American College of Cardiology.
Insulin resistance is known to increase atherogenesis and atherosclerotic plaque instability, resulting in greater risk for MI. The cluster of conditions known as metabolic syndrome (hypertension, hyperlipidemia, hyperglycemia, and abnormal cholesterol levels) has been associated with increased risk of heart disease, diabetes, and stroke.
Among veterans with PTSD, 35% had insulin resistance and 53% had metabolic syndrome, compared with 19% and 38%, respectively, in the non-PTSD group before adjusting for other factors, showing relative risk increases of roughly 80% and 40%. PTSD remained independently associated with higher rates of insulin resistance and metabolic syndrome after controlling for other risk factors, said Dr. Ebrahimi of the University of California, Los Angeles.
The investigators analyzed electronic medical records from primary care settings in the Veterans Health Administration for patients in Southern California and Nevada without known diabetes or coronary artery disease who were followed for a median of 2 years.
Although the PTSD and non-PTSD groups were similar at baseline in age, gender, lipid measures, fasting blood sugar measures, and conventional risk factors for insulin resistance and metabolic syndrome, the PTSD group developed significantly higher levels of triglycerides and fasting blood sugar, lower HDL levels, and a higher triglyceride to HDL ratio, compared with the non-PTSD group. At baseline, the veterans had a mean age of 60 years and 93% were male.
The findings may help clinicians identify and treat cardiovascular risks earlier in patients with PTSD, Dr. Ebrahimi suggested at a press conference at the meeting. Early-stage insulin resistance and metabolic syndrome can be reversed with lifestyle modifications in diet and exercise, and a more integrated approach to treating PTSD may be warranted.
The investigators now are studying the relationship of early PTSD treatment and the risk for insulin resistance and metabolic syndrome. They also are examining the effects of combined psychiatric and medical management of PTSD on the risks of metabolic disorders, MI, stroke, and death.
Whether the PTSD itself or something associated with PTSD increases the risks for insulin resistance and metabolic syndrome once PTSD is diagnosed, "these patients must be looked at a little more closely, and the risk factors in general have to be controlled a little bit more vigilantly," said Dr. Ebrahimi, who is also an interventional cardiologist in the Veterans Affairs Greater Los Angeles Healthcare System.
Nearly 8 million U.S. residents have PTSD, which is now recognized to be prevalent not only in veterans but in the broader population. "It happens when you are in an accident or have an experience that confers significant stress, health damage, or death," including rape and other traumatic events, he said.
The study defined insulin resistance as a triglyceride/HDL ratio of 3.8 or greater. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Program III guidelines.
Dr. Ebrahimi disclosed financial relationships with Boehringer Ingelheim, Abbott Vascular, the Medicines Company, Sanofi-Aventis, and Gilead.
*Correction 3/27/2013: An earlier version of this article included different percentages of insulin resistance and metabolic syndrome in the Major Finding section of this page.
SAN FRANCISCO – Posttraumatic stress disorder independently increased the risk of insulin resistance by 80% and metabolic syndrome by 40% in a retrospective study of 207,954 veterans.
The incidence of insulin resistance was 14% higher and the incidence of metabolic syndrome was 12% higher in 11,420 veterans with posttraumatic stress disorder (PTSD), compared with 196,534 without PTSD, after adjusting for the effects of age, gender, ethnicity, high blood pressure, high cholesterol, family history of premature coronary artery disease, and obesity, study coleader Dr. Ramin Ebrahimi reported at the annual meeting of the American College of Cardiology.
Insulin resistance is known to increase atherogenesis and atherosclerotic plaque instability, resulting in greater risk for MI. The cluster of conditions known as metabolic syndrome (hypertension, hyperlipidemia, hyperglycemia, and abnormal cholesterol levels) has been associated with increased risk of heart disease, diabetes, and stroke.
Among veterans with PTSD, 35% had insulin resistance and 53% had metabolic syndrome, compared with 19% and 38%, respectively, in the non-PTSD group before adjusting for other factors, showing relative risk increases of roughly 80% and 40%. PTSD remained independently associated with higher rates of insulin resistance and metabolic syndrome after controlling for other risk factors, said Dr. Ebrahimi of the University of California, Los Angeles.
The investigators analyzed electronic medical records from primary care settings in the Veterans Health Administration for patients in Southern California and Nevada without known diabetes or coronary artery disease who were followed for a median of 2 years.
Although the PTSD and non-PTSD groups were similar at baseline in age, gender, lipid measures, fasting blood sugar measures, and conventional risk factors for insulin resistance and metabolic syndrome, the PTSD group developed significantly higher levels of triglycerides and fasting blood sugar, lower HDL levels, and a higher triglyceride to HDL ratio, compared with the non-PTSD group. At baseline, the veterans had a mean age of 60 years and 93% were male.
The findings may help clinicians identify and treat cardiovascular risks earlier in patients with PTSD, Dr. Ebrahimi suggested at a press conference at the meeting. Early-stage insulin resistance and metabolic syndrome can be reversed with lifestyle modifications in diet and exercise, and a more integrated approach to treating PTSD may be warranted.
The investigators now are studying the relationship of early PTSD treatment and the risk for insulin resistance and metabolic syndrome. They also are examining the effects of combined psychiatric and medical management of PTSD on the risks of metabolic disorders, MI, stroke, and death.
Whether the PTSD itself or something associated with PTSD increases the risks for insulin resistance and metabolic syndrome once PTSD is diagnosed, "these patients must be looked at a little more closely, and the risk factors in general have to be controlled a little bit more vigilantly," said Dr. Ebrahimi, who is also an interventional cardiologist in the Veterans Affairs Greater Los Angeles Healthcare System.
Nearly 8 million U.S. residents have PTSD, which is now recognized to be prevalent not only in veterans but in the broader population. "It happens when you are in an accident or have an experience that confers significant stress, health damage, or death," including rape and other traumatic events, he said.
The study defined insulin resistance as a triglyceride/HDL ratio of 3.8 or greater. Metabolic syndrome was defined by National Cholesterol Education Program Adult Treatment Program III guidelines.
Dr. Ebrahimi disclosed financial relationships with Boehringer Ingelheim, Abbott Vascular, the Medicines Company, Sanofi-Aventis, and Gilead.
*Correction 3/27/2013: An earlier version of this article included different percentages of insulin resistance and metabolic syndrome in the Major Finding section of this page.
AT ACC 13
Major finding: *The incidence of insulin resistance was 14% higher and the incidence of metabolic syndrome was 12% higher in patients with PTSD, compared with those without PTSD.
Data source: Retrospective study of 207,954 veterans in two states.
Disclosures: Dr. Ebrahimi disclosed financial relationships with Boehringer Ingelheim, Abbott Vascular, the Medicines Company, Sanofi-Aventis, and Gilead.
PLCO criteria catch more lung cancers
Modified criteria for screening current or former smokers for lung cancer appeared to be more accurate than currently recommended criteria.
In a post hoc statistical analysis of data on 28,288 people, a version of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial criteria identified 81 more lung cancers and would have saved an additional 12 lives over a 6-year period, compared with the National Lung Screening Trial (NLST) criteria, Martin C. Tammemägi, Ph.D., and his associates reported.
The modified PLCO criteria were significantly more sensitive than the NLST criteria (83% vs. 71%, respectively) and had a better positive predictive value (4% vs. 3.4%) with no loss of specificity (62% each). Use of the PLCO criteria would have missed 41% fewer cancers, reported Dr. Tammemägi of Brock University, St. Catharines, Ont. (N. Engl. J. Med. 2013;368:728-36).
The American Cancer Society and several other organizations recommend using the NLST criteria, or a version of the criteria, to identify people at high risk of lung cancer who might benefit from screening with low-dose CT imaging. Using the NLST criteria would reduce deaths from lung cancer by 20% (N. Engl. J. Med. 2011;365:395-409). Risk factors include an age between 55 and 74 years, at least a 30 pack-year history of smoking, and no more than 15 years since quitting smoking.
The PLCO criteria added risk factors excluded in the NLST, such as education level (as a proxy for socioeconomic status); body mass index; a family history of lung cancer; chronic obstructive pulmonary disease; chest x-ray within the last 3 years; and not only a history of smoking in pack-years but also the duration of smoking. The PLCO model can be cumbersome to apply because it uses complicated modeling procedures. A spreadsheet for calculating the 6-year risk for lung cancer in a current or former smoker using the PLCO criteria in Dr. Tammemägi’s report can be downloaded here.
The PLCO trial followed patients for a median of 9 years, longer than the median 6-year follow-up in the NLST. The investigators modified the PLCO criteria so that it was directly applicable to patients in the NLST and truncated PLCO follow-up so that they could compare data on 14,144 people in each of the studies. The modified PLCO model was developed and validated using data on 80,375 people in the PLCO trial.
Among people who did not qualify for screening under PLCO criteria, 0.5% developed lung cancer, a significantly smaller proportion than the 0.85% of patients excluded from screening under NLST criteria who then developed lung cancer, Dr. Tammemägi reported. Overall, the modified PLCO criteria identified 12% more of the 678 lung cancers in the total cohort than did NLST criteria. The modified PLCO criteria missed 115 lung cancers; the NLST criteria missed 196.
In the PLCO model, current or former smokers were more likely to develop lung cancer with increasing age; black vs. white race; lower socioeconomic status; lower BMI, self-reported history of chronic obstructive pulmonary disease; family history of lung cancer; current smoking; increasing number of cigarettes smoked per day; duration of smoking; and shorter time since quitting, if no longer smoking.
Prospective studies should evaluate the modified PLCO criteria in different populations and clinical and public health settings, Dr. Tammemägi suggested. Additional risk factors may be added to the model in the future to enhance its predictive accuracy.
Dr. Tammemägi reported having no financial disclosures.
Modified criteria for screening current or former smokers for lung cancer appeared to be more accurate than currently recommended criteria.
In a post hoc statistical analysis of data on 28,288 people, a version of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial criteria identified 81 more lung cancers and would have saved an additional 12 lives over a 6-year period, compared with the National Lung Screening Trial (NLST) criteria, Martin C. Tammemägi, Ph.D., and his associates reported.
The modified PLCO criteria were significantly more sensitive than the NLST criteria (83% vs. 71%, respectively) and had a better positive predictive value (4% vs. 3.4%) with no loss of specificity (62% each). Use of the PLCO criteria would have missed 41% fewer cancers, reported Dr. Tammemägi of Brock University, St. Catharines, Ont. (N. Engl. J. Med. 2013;368:728-36).
The American Cancer Society and several other organizations recommend using the NLST criteria, or a version of the criteria, to identify people at high risk of lung cancer who might benefit from screening with low-dose CT imaging. Using the NLST criteria would reduce deaths from lung cancer by 20% (N. Engl. J. Med. 2011;365:395-409). Risk factors include an age between 55 and 74 years, at least a 30 pack-year history of smoking, and no more than 15 years since quitting smoking.
The PLCO criteria added risk factors excluded in the NLST, such as education level (as a proxy for socioeconomic status); body mass index; a family history of lung cancer; chronic obstructive pulmonary disease; chest x-ray within the last 3 years; and not only a history of smoking in pack-years but also the duration of smoking. The PLCO model can be cumbersome to apply because it uses complicated modeling procedures. A spreadsheet for calculating the 6-year risk for lung cancer in a current or former smoker using the PLCO criteria in Dr. Tammemägi’s report can be downloaded here.
The PLCO trial followed patients for a median of 9 years, longer than the median 6-year follow-up in the NLST. The investigators modified the PLCO criteria so that it was directly applicable to patients in the NLST and truncated PLCO follow-up so that they could compare data on 14,144 people in each of the studies. The modified PLCO model was developed and validated using data on 80,375 people in the PLCO trial.
Among people who did not qualify for screening under PLCO criteria, 0.5% developed lung cancer, a significantly smaller proportion than the 0.85% of patients excluded from screening under NLST criteria who then developed lung cancer, Dr. Tammemägi reported. Overall, the modified PLCO criteria identified 12% more of the 678 lung cancers in the total cohort than did NLST criteria. The modified PLCO criteria missed 115 lung cancers; the NLST criteria missed 196.
In the PLCO model, current or former smokers were more likely to develop lung cancer with increasing age; black vs. white race; lower socioeconomic status; lower BMI, self-reported history of chronic obstructive pulmonary disease; family history of lung cancer; current smoking; increasing number of cigarettes smoked per day; duration of smoking; and shorter time since quitting, if no longer smoking.
Prospective studies should evaluate the modified PLCO criteria in different populations and clinical and public health settings, Dr. Tammemägi suggested. Additional risk factors may be added to the model in the future to enhance its predictive accuracy.
Dr. Tammemägi reported having no financial disclosures.
Modified criteria for screening current or former smokers for lung cancer appeared to be more accurate than currently recommended criteria.
In a post hoc statistical analysis of data on 28,288 people, a version of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial criteria identified 81 more lung cancers and would have saved an additional 12 lives over a 6-year period, compared with the National Lung Screening Trial (NLST) criteria, Martin C. Tammemägi, Ph.D., and his associates reported.
The modified PLCO criteria were significantly more sensitive than the NLST criteria (83% vs. 71%, respectively) and had a better positive predictive value (4% vs. 3.4%) with no loss of specificity (62% each). Use of the PLCO criteria would have missed 41% fewer cancers, reported Dr. Tammemägi of Brock University, St. Catharines, Ont. (N. Engl. J. Med. 2013;368:728-36).
The American Cancer Society and several other organizations recommend using the NLST criteria, or a version of the criteria, to identify people at high risk of lung cancer who might benefit from screening with low-dose CT imaging. Using the NLST criteria would reduce deaths from lung cancer by 20% (N. Engl. J. Med. 2011;365:395-409). Risk factors include an age between 55 and 74 years, at least a 30 pack-year history of smoking, and no more than 15 years since quitting smoking.
The PLCO criteria added risk factors excluded in the NLST, such as education level (as a proxy for socioeconomic status); body mass index; a family history of lung cancer; chronic obstructive pulmonary disease; chest x-ray within the last 3 years; and not only a history of smoking in pack-years but also the duration of smoking. The PLCO model can be cumbersome to apply because it uses complicated modeling procedures. A spreadsheet for calculating the 6-year risk for lung cancer in a current or former smoker using the PLCO criteria in Dr. Tammemägi’s report can be downloaded here.
The PLCO trial followed patients for a median of 9 years, longer than the median 6-year follow-up in the NLST. The investigators modified the PLCO criteria so that it was directly applicable to patients in the NLST and truncated PLCO follow-up so that they could compare data on 14,144 people in each of the studies. The modified PLCO model was developed and validated using data on 80,375 people in the PLCO trial.
Among people who did not qualify for screening under PLCO criteria, 0.5% developed lung cancer, a significantly smaller proportion than the 0.85% of patients excluded from screening under NLST criteria who then developed lung cancer, Dr. Tammemägi reported. Overall, the modified PLCO criteria identified 12% more of the 678 lung cancers in the total cohort than did NLST criteria. The modified PLCO criteria missed 115 lung cancers; the NLST criteria missed 196.
In the PLCO model, current or former smokers were more likely to develop lung cancer with increasing age; black vs. white race; lower socioeconomic status; lower BMI, self-reported history of chronic obstructive pulmonary disease; family history of lung cancer; current smoking; increasing number of cigarettes smoked per day; duration of smoking; and shorter time since quitting, if no longer smoking.
Prospective studies should evaluate the modified PLCO criteria in different populations and clinical and public health settings, Dr. Tammemägi suggested. Additional risk factors may be added to the model in the future to enhance its predictive accuracy.
Dr. Tammemägi reported having no financial disclosures.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Major Finding: Using the modified PLCO criteria identified 12% more of the 678 lung cancers in the total cohort than did NLST criteria.
Data Source: Post hoc statistical analyses of data on 28,288 people, 14,144 each from the PLCO trial and the NLST.
Disclosures: Dr. Tammemägi reported having no financial disclosures.
Intense statin therapy treats atheromas in diabetes
SAN FRANCISCO – Atheromas regressed to similar degrees in patients with or without diabetes on high-intensity statin therapy for symptomatic coronary artery disease, a post hoc subgroup analysis of 1,039 patients found.
The primary endpoint, percent atheroma volume (PAV), decreased by a mean of 1.04% in 159 diabetic patients and by 1.21% in 880 nondiabetic patients compared with baseline – significant drops in both groups, Dr. Brian Stegman and his associates reported. PAV is the percentage of a single vessel’s volume occupied by atheroma.
The total atheroma volume (TAV), a secondary endpoint, decreased compared with baseline by 5.62 mm3 in the diabetic group and by 7.29 mm3 in the nondiabetic group, both of which also were significant changes, he said at the annual meeting of the American College of Cardiology.
Data came from the SATURN (Study of Coronary Atheroma by Intravascular Ultrasound: Effect of Rosuvastatin Versus Atorvastatin) trial, which compared intensive therapy with one of the two statin drugs in patients who underwent serial intravascular ultrasonography to assess disease regression. Patients were treated with either 40 mg/day rosuvastatin or 80 mg/day atorvastatin for 2 years. The two drug groups showed similar reductions in PAV, with a greater reduction in TAV using rosuvastatin (N. Engl. J. Med. 2011;365:2078-87).
Previous studies using have shown that aggressive reductions in LDL levels lead to significant regression in coronary atheromas as measured by intravascular ultrasound, but it has not been clear whether this is true in patients with diabetes as well as those without, said Dr. Stegman of the Cleveland Clinic Foundation.
The current analysis regrouped the SATURN cohort by diabetes status. High-intensity statin therapy produced substantial reductions in LDL in both groups, to a similar degree: a 52-mg/dL drop in diabetics and a 55-mg/dL decrease in nondiabetics. HDL levels increased by 3 mg/dL in diabetics and 5 mg/dL in nondiabetics, a significant difference between groups. Total cholesterol decreased 52 mg/dL in diabetics and 54 mg/dL in nondiabetics, and triglyceride levels decreased 13 mg/dL in diabetics and 12 mg/dL in nondiabetics, measures that were not significantly different between groups.
In both diabetics and nondiabetics, the lower the LDL on treatment, the greater the regression of atheroma, according to a linear regression model constructed by the investigators.
The changes in PAV and TAV in both groups showed that "with high-intensity statin therapy, we saw equal regression of atheroma in diabetics compared with nondiabetics," Dr. Stegman said. Lumen volumes were preserved over the 2-year period to a similar degree in both groups, as measured by change in lumen volume and external elastic membrane volume.
The findings differ from previous results in a pooled analysis of five trials involving intravascular ultrasound measurements of atherosclerosis progression in 2,237 patients, 416 of whom had diabetes, he noted. In that analysis, PAV increased by 0.05% in diabetics and by 0.6% in nondiabetics, compared with decreases of 1.21% and 1.04%, respectively, in the current analysis. *The TAV decreased by 2.7 mm3 in diabetics and 0.6 mm3 in nondiabetics, much less than the 5.62-mm3 and 7.29-mm3decreases, respectively, in the current analysis (J. Am. Coll. Cardiol. 2008;52:255-62).
The different outcomes in the two analyses may be due to less aggressive treatment in the trials pooled in the 2008 analysis, which did not decrease LDL levels as much as the high-intensity regimens in the SATURN trial. "I think our current study indicates that diabetic patients require fairly aggressive lipid therapy to get the same results as in nondiabetic patients," Dr. Stegman said.
Separate, previous trials using intravascular ultrasound have shown that high-dose statin therapy is more effective than moderate- or low dose regimens to halt progression of atherosclerosis, he added.
The analysis is limited by its post hoc nature, differing patient numbers in each group, and differences in baseline characteristics. Patients in the diabetic group were significantly older, with a higher mean body mass index, and more likely to be female and to have a history of hypertension compared with nondiabetics. Baseline lipid levels were significantly different between groups, with lower total cholesterol, LDL, and HDL levels and higher triglyceride levels in patients with diabetes. Intravascular ultrasound measurements also differed significantly, with greater PAV and TAV in the diabetic group.
The PAV and TAV endpoints were surrogate measures of clinical outcomes, another limitation of the analysis, but previous studies with intravascular ultrasound have reported that greater PAV and greater progression of PAV are associated with an increased risk of major adverse cardiovascular events, he said.
Dr. Stegman reported having no relevant financial disclosures. Some of his associates in the study reported financial associations with multiple pharmaceutical companies, several of which market statins.
*Correction, 3/27/13: An earlier version of this story incorrectly reported decreased TAV numbers for diabetics and nondiabetics. This version has been updated to reflect the correct numbers.
On Twitter @sherryboschert
SAN FRANCISCO – Atheromas regressed to similar degrees in patients with or without diabetes on high-intensity statin therapy for symptomatic coronary artery disease, a post hoc subgroup analysis of 1,039 patients found.
The primary endpoint, percent atheroma volume (PAV), decreased by a mean of 1.04% in 159 diabetic patients and by 1.21% in 880 nondiabetic patients compared with baseline – significant drops in both groups, Dr. Brian Stegman and his associates reported. PAV is the percentage of a single vessel’s volume occupied by atheroma.
The total atheroma volume (TAV), a secondary endpoint, decreased compared with baseline by 5.62 mm3 in the diabetic group and by 7.29 mm3 in the nondiabetic group, both of which also were significant changes, he said at the annual meeting of the American College of Cardiology.
Data came from the SATURN (Study of Coronary Atheroma by Intravascular Ultrasound: Effect of Rosuvastatin Versus Atorvastatin) trial, which compared intensive therapy with one of the two statin drugs in patients who underwent serial intravascular ultrasonography to assess disease regression. Patients were treated with either 40 mg/day rosuvastatin or 80 mg/day atorvastatin for 2 years. The two drug groups showed similar reductions in PAV, with a greater reduction in TAV using rosuvastatin (N. Engl. J. Med. 2011;365:2078-87).
Previous studies using have shown that aggressive reductions in LDL levels lead to significant regression in coronary atheromas as measured by intravascular ultrasound, but it has not been clear whether this is true in patients with diabetes as well as those without, said Dr. Stegman of the Cleveland Clinic Foundation.
The current analysis regrouped the SATURN cohort by diabetes status. High-intensity statin therapy produced substantial reductions in LDL in both groups, to a similar degree: a 52-mg/dL drop in diabetics and a 55-mg/dL decrease in nondiabetics. HDL levels increased by 3 mg/dL in diabetics and 5 mg/dL in nondiabetics, a significant difference between groups. Total cholesterol decreased 52 mg/dL in diabetics and 54 mg/dL in nondiabetics, and triglyceride levels decreased 13 mg/dL in diabetics and 12 mg/dL in nondiabetics, measures that were not significantly different between groups.
In both diabetics and nondiabetics, the lower the LDL on treatment, the greater the regression of atheroma, according to a linear regression model constructed by the investigators.
The changes in PAV and TAV in both groups showed that "with high-intensity statin therapy, we saw equal regression of atheroma in diabetics compared with nondiabetics," Dr. Stegman said. Lumen volumes were preserved over the 2-year period to a similar degree in both groups, as measured by change in lumen volume and external elastic membrane volume.
The findings differ from previous results in a pooled analysis of five trials involving intravascular ultrasound measurements of atherosclerosis progression in 2,237 patients, 416 of whom had diabetes, he noted. In that analysis, PAV increased by 0.05% in diabetics and by 0.6% in nondiabetics, compared with decreases of 1.21% and 1.04%, respectively, in the current analysis. *The TAV decreased by 2.7 mm3 in diabetics and 0.6 mm3 in nondiabetics, much less than the 5.62-mm3 and 7.29-mm3decreases, respectively, in the current analysis (J. Am. Coll. Cardiol. 2008;52:255-62).
The different outcomes in the two analyses may be due to less aggressive treatment in the trials pooled in the 2008 analysis, which did not decrease LDL levels as much as the high-intensity regimens in the SATURN trial. "I think our current study indicates that diabetic patients require fairly aggressive lipid therapy to get the same results as in nondiabetic patients," Dr. Stegman said.
Separate, previous trials using intravascular ultrasound have shown that high-dose statin therapy is more effective than moderate- or low dose regimens to halt progression of atherosclerosis, he added.
The analysis is limited by its post hoc nature, differing patient numbers in each group, and differences in baseline characteristics. Patients in the diabetic group were significantly older, with a higher mean body mass index, and more likely to be female and to have a history of hypertension compared with nondiabetics. Baseline lipid levels were significantly different between groups, with lower total cholesterol, LDL, and HDL levels and higher triglyceride levels in patients with diabetes. Intravascular ultrasound measurements also differed significantly, with greater PAV and TAV in the diabetic group.
The PAV and TAV endpoints were surrogate measures of clinical outcomes, another limitation of the analysis, but previous studies with intravascular ultrasound have reported that greater PAV and greater progression of PAV are associated with an increased risk of major adverse cardiovascular events, he said.
Dr. Stegman reported having no relevant financial disclosures. Some of his associates in the study reported financial associations with multiple pharmaceutical companies, several of which market statins.
*Correction, 3/27/13: An earlier version of this story incorrectly reported decreased TAV numbers for diabetics and nondiabetics. This version has been updated to reflect the correct numbers.
On Twitter @sherryboschert
SAN FRANCISCO – Atheromas regressed to similar degrees in patients with or without diabetes on high-intensity statin therapy for symptomatic coronary artery disease, a post hoc subgroup analysis of 1,039 patients found.
The primary endpoint, percent atheroma volume (PAV), decreased by a mean of 1.04% in 159 diabetic patients and by 1.21% in 880 nondiabetic patients compared with baseline – significant drops in both groups, Dr. Brian Stegman and his associates reported. PAV is the percentage of a single vessel’s volume occupied by atheroma.
The total atheroma volume (TAV), a secondary endpoint, decreased compared with baseline by 5.62 mm3 in the diabetic group and by 7.29 mm3 in the nondiabetic group, both of which also were significant changes, he said at the annual meeting of the American College of Cardiology.
Data came from the SATURN (Study of Coronary Atheroma by Intravascular Ultrasound: Effect of Rosuvastatin Versus Atorvastatin) trial, which compared intensive therapy with one of the two statin drugs in patients who underwent serial intravascular ultrasonography to assess disease regression. Patients were treated with either 40 mg/day rosuvastatin or 80 mg/day atorvastatin for 2 years. The two drug groups showed similar reductions in PAV, with a greater reduction in TAV using rosuvastatin (N. Engl. J. Med. 2011;365:2078-87).
Previous studies using have shown that aggressive reductions in LDL levels lead to significant regression in coronary atheromas as measured by intravascular ultrasound, but it has not been clear whether this is true in patients with diabetes as well as those without, said Dr. Stegman of the Cleveland Clinic Foundation.
The current analysis regrouped the SATURN cohort by diabetes status. High-intensity statin therapy produced substantial reductions in LDL in both groups, to a similar degree: a 52-mg/dL drop in diabetics and a 55-mg/dL decrease in nondiabetics. HDL levels increased by 3 mg/dL in diabetics and 5 mg/dL in nondiabetics, a significant difference between groups. Total cholesterol decreased 52 mg/dL in diabetics and 54 mg/dL in nondiabetics, and triglyceride levels decreased 13 mg/dL in diabetics and 12 mg/dL in nondiabetics, measures that were not significantly different between groups.
In both diabetics and nondiabetics, the lower the LDL on treatment, the greater the regression of atheroma, according to a linear regression model constructed by the investigators.
The changes in PAV and TAV in both groups showed that "with high-intensity statin therapy, we saw equal regression of atheroma in diabetics compared with nondiabetics," Dr. Stegman said. Lumen volumes were preserved over the 2-year period to a similar degree in both groups, as measured by change in lumen volume and external elastic membrane volume.
The findings differ from previous results in a pooled analysis of five trials involving intravascular ultrasound measurements of atherosclerosis progression in 2,237 patients, 416 of whom had diabetes, he noted. In that analysis, PAV increased by 0.05% in diabetics and by 0.6% in nondiabetics, compared with decreases of 1.21% and 1.04%, respectively, in the current analysis. *The TAV decreased by 2.7 mm3 in diabetics and 0.6 mm3 in nondiabetics, much less than the 5.62-mm3 and 7.29-mm3decreases, respectively, in the current analysis (J. Am. Coll. Cardiol. 2008;52:255-62).
The different outcomes in the two analyses may be due to less aggressive treatment in the trials pooled in the 2008 analysis, which did not decrease LDL levels as much as the high-intensity regimens in the SATURN trial. "I think our current study indicates that diabetic patients require fairly aggressive lipid therapy to get the same results as in nondiabetic patients," Dr. Stegman said.
Separate, previous trials using intravascular ultrasound have shown that high-dose statin therapy is more effective than moderate- or low dose regimens to halt progression of atherosclerosis, he added.
The analysis is limited by its post hoc nature, differing patient numbers in each group, and differences in baseline characteristics. Patients in the diabetic group were significantly older, with a higher mean body mass index, and more likely to be female and to have a history of hypertension compared with nondiabetics. Baseline lipid levels were significantly different between groups, with lower total cholesterol, LDL, and HDL levels and higher triglyceride levels in patients with diabetes. Intravascular ultrasound measurements also differed significantly, with greater PAV and TAV in the diabetic group.
The PAV and TAV endpoints were surrogate measures of clinical outcomes, another limitation of the analysis, but previous studies with intravascular ultrasound have reported that greater PAV and greater progression of PAV are associated with an increased risk of major adverse cardiovascular events, he said.
Dr. Stegman reported having no relevant financial disclosures. Some of his associates in the study reported financial associations with multiple pharmaceutical companies, several of which market statins.
*Correction, 3/27/13: An earlier version of this story incorrectly reported decreased TAV numbers for diabetics and nondiabetics. This version has been updated to reflect the correct numbers.
On Twitter @sherryboschert
AT ACC 13
Major finding: The percent atheroma volume after high-intensity statin therapy decreased by 1.04% in diabetic patients and by 1.21% in nondiabetic patients, significant drops in both groups.
Data source: Post hoc analysis of prospective randomized trial in 1,039 patients with symptomatic coronary artery disease who underwent serial intravascular ultrasonography.
Disclosures: Dr. Stegman reported having no disclosures. Some of his associates in the study reported financial associations with multiple pharmaceutical companies, several of which market statins.
PARTNER outcomes hold firm over time
SAN FRANCISCO – Transcatheter aortic valve replacements seem to be holding up without feared increases in rates of stroke or regurgitation beyond what’s seen soon after the procedure, 3-year data from the PARTNER trial of 699 elderly, high-risk patients showed.
Rates of death from any cause were similar between patients randomized to transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) at each yearly follow-up so far. Those rates (the primary endpoint of the trial) were 24.3% in the TAVR group and 26.8% in SAVR group at 1 year, 33.7% and 34.6% at 2 years, and 442% and 44.8% at 3 years, respectively, according to ongoing follow-up of the PARTNER (Transcatheter vs. Surgical Aortic-Valve Replacement in High-Risk Patients) study.
Previously data had shown a higher stroke rate within 30 days of TAVR (5%), compared with SAVR (2%), though the difference did not reach statistical significance. By 3 years, the stroke rate in the surgery group caught up and even surpassed that in the TAVR group. After TAVR, stroke rates were 6% at 1 year, 8% at 2 years and 8% at 3 years, compared with rates of 3%, 5% and 9%, respectively, in the SAVR group, Dr. Vinod H. Thourani and his associates reported at the annual meeting of the American College of Cardiology. None of the stroke differences reached statistical significance.
Paravalvular leaks were common and more likely with TAVR at all follow-up time points. Even mild leakage after either procedure was associated with an unexpected, significantly increased risk of death, said Dr. Thourani, codirector of the Structural Heart and Valve Center and associate professor of cardiology at Emory University, Atlanta. Death rates in patients with mild aortic regurgitation of any kind (paravalvular or central) after TAVR were 26% at year 1, 32% at year 2, and 47% at year 3. For moderate to severe aortic regurgitation after TAVR, death rates increased to 38% at 1 year, 54% at 2 years, and 61% at 3 years.
The increased death risk with mild regurgitation has not shown up in European patient registries and caught investigators by surprise. The reason for this association in the study is a mystery, he said.
Echocardiographic analysis showed that hemodynamic performance after TAVR was maintained at 3 years, with similar valve areas and gradients, compared with SAVR. Both groups had significant improvements in left ventricular ejection fractions and left ventricular mass.
The PARTNER study included elderly patients with severe aortic stenosis who had a Society of Thoracic Surgeons (STS) score of at least 10%, suggesting they would be at high risk from surgery. Patients were randomized to undergo TAVR or SAVR at 1 of 25 sites in three countries and those in the TAVR group were further randomized to either transfemoral or transapical approach to placement of the balloon-expandable bovine pericardial valve, the first-generation Edwards SAPIEN transcatheter heart valve system (N. Engl. J. Med. 2011;364:2187-98).
Combining all-cause mortality or strokes, rates for TAVR and SAVR at 1 year were 27% and 29%, respectively, at 2 years were 37% and 36%, and at 3 years were 47% and 46%, respectively, he said.
Among clinical outcomes, rates of major vascular complications were significantly higher in the TAVR group, compared with SAVR: 12% vs. 4% at year 1, rates that held steady in years 2 and 3. Major bleeding was significantly less likely in the TAVR group each year, compared with SAVR: 16% vs. 27% in year 1, 19% vs. 30% in year 2, and 21% vs. 32% in year 3. Rates of endocarditis were similar between groups each year. No patients in either group developed structural valve deterioration requiring aortic valve replacement. Roughly 80% in each group had relief of symptoms.
Future efforts should aim to reduce procedure-related complications from TAVR, including strokes, vascular events, and paravalvular regurgitation, Dr. Thourani said.
"With a 44% mortality at 3 years, what we have to learn is how to select better patients," Dr. Bernard J. Gersh commented during a panel discussion of the findings. Dr. Gersh is professor of medicine at the Mayo Clinic, Rochester, Minn.
Experts in Europe have begun a series of meetings to try to define a transcatheter-specific risk score that might be a better gauge than the STS score in selecting patients for TAVR, Dr. Thourani said.
Patients in the current analysis have a minimum of 3 years of follow-up, so the findings really give a hint of 3- to 5-year results, Dr. Thourani said. "I think we can say something about the durability of these valves."
Dr. Patrick T. O’Gara cautioned against generalizing results from the PARTNER cohort, which averaged 84 years in age. "We have durability information in the octogenarian group over 3 years of time. When we think about deploying this kind of technology in younger and healthier individuals, there remain concerns about durability and about paravalvular leaks," he said at a press briefing.
Concerns about some findings, such as the 44% mortality rate at 3 years, may amount to unnecessarily "throwing darts" at the TAVR results, he suggested. "Let’s remember that we’re dealing with a group of patients who are 84 years of age on average. Our expectations for their outcomes need to be tempered by the context in which these procedures are offered," said Dr. O’Gara, director of clinical cardiology at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, Boston.
Each TAVR costs approximately $70,000-$75,000, Dr. Thourani estimated.
Edwards Lifesciences, which makes the transcatheter valve replacement systems, funded the PARTNER trial, and Dr. Thourani and some of his coinvestigators disclosed financial relationships with the company. He also disclosed relationships with St. Jude Medical, Marquet Medical, Sorin Medical, and Medtronic. Dr. O’Gara had nothing to disclose. Dr. Gersh disclosed financial relationships with St. Jude Medical and Boston Scientific.
Twitter @sherryboschert
There’s no question that TAVR is here to stay. In PARTNER and in registries from Europe, the valves have been shown to be durable. The 3-year outcomes are superb, compared with conventional AVR. We don’t know about years, 5, 6, 7, or 8; we still have to follow.
One of the questions here, as the valve gets better moving forward, is to define who is the best target for this. We’ve all seen the bar coming down from use in extremely high-risk patients, and now there are more and more trials in lower-risk patients.
On the other side of the fence, in very-high-risk patients, there is a time when people may be so high risk that we would be doing something futile. With such an expensive surgery, we have to "tune up" that a little bit. I hope that we refine those criteria in the future.
Aortic valve replacements frequently leak, and leaks can be mild, moderate, or severe. In the PARTNER trial, even a mild leak was associated with a higher risk of events over the follow-up period, which in the European registries doesn’t show up. That still remains a mystery. It may be a marker of something else that is going on with these patients.
Dr. Miguel A. Quiñones is a professor of medicine at Cornell University, New York, and chair of cardiology in the Methodist Hospital System, Houston, Tex. These were some of his comments at a press briefing after Dr. Thourani’s presentation. He had no disclosures.
There’s no question that TAVR is here to stay. In PARTNER and in registries from Europe, the valves have been shown to be durable. The 3-year outcomes are superb, compared with conventional AVR. We don’t know about years, 5, 6, 7, or 8; we still have to follow.
One of the questions here, as the valve gets better moving forward, is to define who is the best target for this. We’ve all seen the bar coming down from use in extremely high-risk patients, and now there are more and more trials in lower-risk patients.
On the other side of the fence, in very-high-risk patients, there is a time when people may be so high risk that we would be doing something futile. With such an expensive surgery, we have to "tune up" that a little bit. I hope that we refine those criteria in the future.
Aortic valve replacements frequently leak, and leaks can be mild, moderate, or severe. In the PARTNER trial, even a mild leak was associated with a higher risk of events over the follow-up period, which in the European registries doesn’t show up. That still remains a mystery. It may be a marker of something else that is going on with these patients.
Dr. Miguel A. Quiñones is a professor of medicine at Cornell University, New York, and chair of cardiology in the Methodist Hospital System, Houston, Tex. These were some of his comments at a press briefing after Dr. Thourani’s presentation. He had no disclosures.
There’s no question that TAVR is here to stay. In PARTNER and in registries from Europe, the valves have been shown to be durable. The 3-year outcomes are superb, compared with conventional AVR. We don’t know about years, 5, 6, 7, or 8; we still have to follow.
One of the questions here, as the valve gets better moving forward, is to define who is the best target for this. We’ve all seen the bar coming down from use in extremely high-risk patients, and now there are more and more trials in lower-risk patients.
On the other side of the fence, in very-high-risk patients, there is a time when people may be so high risk that we would be doing something futile. With such an expensive surgery, we have to "tune up" that a little bit. I hope that we refine those criteria in the future.
Aortic valve replacements frequently leak, and leaks can be mild, moderate, or severe. In the PARTNER trial, even a mild leak was associated with a higher risk of events over the follow-up period, which in the European registries doesn’t show up. That still remains a mystery. It may be a marker of something else that is going on with these patients.
Dr. Miguel A. Quiñones is a professor of medicine at Cornell University, New York, and chair of cardiology in the Methodist Hospital System, Houston, Tex. These were some of his comments at a press briefing after Dr. Thourani’s presentation. He had no disclosures.
SAN FRANCISCO – Transcatheter aortic valve replacements seem to be holding up without feared increases in rates of stroke or regurgitation beyond what’s seen soon after the procedure, 3-year data from the PARTNER trial of 699 elderly, high-risk patients showed.
Rates of death from any cause were similar between patients randomized to transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) at each yearly follow-up so far. Those rates (the primary endpoint of the trial) were 24.3% in the TAVR group and 26.8% in SAVR group at 1 year, 33.7% and 34.6% at 2 years, and 442% and 44.8% at 3 years, respectively, according to ongoing follow-up of the PARTNER (Transcatheter vs. Surgical Aortic-Valve Replacement in High-Risk Patients) study.
Previously data had shown a higher stroke rate within 30 days of TAVR (5%), compared with SAVR (2%), though the difference did not reach statistical significance. By 3 years, the stroke rate in the surgery group caught up and even surpassed that in the TAVR group. After TAVR, stroke rates were 6% at 1 year, 8% at 2 years and 8% at 3 years, compared with rates of 3%, 5% and 9%, respectively, in the SAVR group, Dr. Vinod H. Thourani and his associates reported at the annual meeting of the American College of Cardiology. None of the stroke differences reached statistical significance.
Paravalvular leaks were common and more likely with TAVR at all follow-up time points. Even mild leakage after either procedure was associated with an unexpected, significantly increased risk of death, said Dr. Thourani, codirector of the Structural Heart and Valve Center and associate professor of cardiology at Emory University, Atlanta. Death rates in patients with mild aortic regurgitation of any kind (paravalvular or central) after TAVR were 26% at year 1, 32% at year 2, and 47% at year 3. For moderate to severe aortic regurgitation after TAVR, death rates increased to 38% at 1 year, 54% at 2 years, and 61% at 3 years.
The increased death risk with mild regurgitation has not shown up in European patient registries and caught investigators by surprise. The reason for this association in the study is a mystery, he said.
Echocardiographic analysis showed that hemodynamic performance after TAVR was maintained at 3 years, with similar valve areas and gradients, compared with SAVR. Both groups had significant improvements in left ventricular ejection fractions and left ventricular mass.
The PARTNER study included elderly patients with severe aortic stenosis who had a Society of Thoracic Surgeons (STS) score of at least 10%, suggesting they would be at high risk from surgery. Patients were randomized to undergo TAVR or SAVR at 1 of 25 sites in three countries and those in the TAVR group were further randomized to either transfemoral or transapical approach to placement of the balloon-expandable bovine pericardial valve, the first-generation Edwards SAPIEN transcatheter heart valve system (N. Engl. J. Med. 2011;364:2187-98).
Combining all-cause mortality or strokes, rates for TAVR and SAVR at 1 year were 27% and 29%, respectively, at 2 years were 37% and 36%, and at 3 years were 47% and 46%, respectively, he said.
Among clinical outcomes, rates of major vascular complications were significantly higher in the TAVR group, compared with SAVR: 12% vs. 4% at year 1, rates that held steady in years 2 and 3. Major bleeding was significantly less likely in the TAVR group each year, compared with SAVR: 16% vs. 27% in year 1, 19% vs. 30% in year 2, and 21% vs. 32% in year 3. Rates of endocarditis were similar between groups each year. No patients in either group developed structural valve deterioration requiring aortic valve replacement. Roughly 80% in each group had relief of symptoms.
Future efforts should aim to reduce procedure-related complications from TAVR, including strokes, vascular events, and paravalvular regurgitation, Dr. Thourani said.
"With a 44% mortality at 3 years, what we have to learn is how to select better patients," Dr. Bernard J. Gersh commented during a panel discussion of the findings. Dr. Gersh is professor of medicine at the Mayo Clinic, Rochester, Minn.
Experts in Europe have begun a series of meetings to try to define a transcatheter-specific risk score that might be a better gauge than the STS score in selecting patients for TAVR, Dr. Thourani said.
Patients in the current analysis have a minimum of 3 years of follow-up, so the findings really give a hint of 3- to 5-year results, Dr. Thourani said. "I think we can say something about the durability of these valves."
Dr. Patrick T. O’Gara cautioned against generalizing results from the PARTNER cohort, which averaged 84 years in age. "We have durability information in the octogenarian group over 3 years of time. When we think about deploying this kind of technology in younger and healthier individuals, there remain concerns about durability and about paravalvular leaks," he said at a press briefing.
Concerns about some findings, such as the 44% mortality rate at 3 years, may amount to unnecessarily "throwing darts" at the TAVR results, he suggested. "Let’s remember that we’re dealing with a group of patients who are 84 years of age on average. Our expectations for their outcomes need to be tempered by the context in which these procedures are offered," said Dr. O’Gara, director of clinical cardiology at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, Boston.
Each TAVR costs approximately $70,000-$75,000, Dr. Thourani estimated.
Edwards Lifesciences, which makes the transcatheter valve replacement systems, funded the PARTNER trial, and Dr. Thourani and some of his coinvestigators disclosed financial relationships with the company. He also disclosed relationships with St. Jude Medical, Marquet Medical, Sorin Medical, and Medtronic. Dr. O’Gara had nothing to disclose. Dr. Gersh disclosed financial relationships with St. Jude Medical and Boston Scientific.
Twitter @sherryboschert
SAN FRANCISCO – Transcatheter aortic valve replacements seem to be holding up without feared increases in rates of stroke or regurgitation beyond what’s seen soon after the procedure, 3-year data from the PARTNER trial of 699 elderly, high-risk patients showed.
Rates of death from any cause were similar between patients randomized to transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) at each yearly follow-up so far. Those rates (the primary endpoint of the trial) were 24.3% in the TAVR group and 26.8% in SAVR group at 1 year, 33.7% and 34.6% at 2 years, and 442% and 44.8% at 3 years, respectively, according to ongoing follow-up of the PARTNER (Transcatheter vs. Surgical Aortic-Valve Replacement in High-Risk Patients) study.
Previously data had shown a higher stroke rate within 30 days of TAVR (5%), compared with SAVR (2%), though the difference did not reach statistical significance. By 3 years, the stroke rate in the surgery group caught up and even surpassed that in the TAVR group. After TAVR, stroke rates were 6% at 1 year, 8% at 2 years and 8% at 3 years, compared with rates of 3%, 5% and 9%, respectively, in the SAVR group, Dr. Vinod H. Thourani and his associates reported at the annual meeting of the American College of Cardiology. None of the stroke differences reached statistical significance.
Paravalvular leaks were common and more likely with TAVR at all follow-up time points. Even mild leakage after either procedure was associated with an unexpected, significantly increased risk of death, said Dr. Thourani, codirector of the Structural Heart and Valve Center and associate professor of cardiology at Emory University, Atlanta. Death rates in patients with mild aortic regurgitation of any kind (paravalvular or central) after TAVR were 26% at year 1, 32% at year 2, and 47% at year 3. For moderate to severe aortic regurgitation after TAVR, death rates increased to 38% at 1 year, 54% at 2 years, and 61% at 3 years.
The increased death risk with mild regurgitation has not shown up in European patient registries and caught investigators by surprise. The reason for this association in the study is a mystery, he said.
Echocardiographic analysis showed that hemodynamic performance after TAVR was maintained at 3 years, with similar valve areas and gradients, compared with SAVR. Both groups had significant improvements in left ventricular ejection fractions and left ventricular mass.
The PARTNER study included elderly patients with severe aortic stenosis who had a Society of Thoracic Surgeons (STS) score of at least 10%, suggesting they would be at high risk from surgery. Patients were randomized to undergo TAVR or SAVR at 1 of 25 sites in three countries and those in the TAVR group were further randomized to either transfemoral or transapical approach to placement of the balloon-expandable bovine pericardial valve, the first-generation Edwards SAPIEN transcatheter heart valve system (N. Engl. J. Med. 2011;364:2187-98).
Combining all-cause mortality or strokes, rates for TAVR and SAVR at 1 year were 27% and 29%, respectively, at 2 years were 37% and 36%, and at 3 years were 47% and 46%, respectively, he said.
Among clinical outcomes, rates of major vascular complications were significantly higher in the TAVR group, compared with SAVR: 12% vs. 4% at year 1, rates that held steady in years 2 and 3. Major bleeding was significantly less likely in the TAVR group each year, compared with SAVR: 16% vs. 27% in year 1, 19% vs. 30% in year 2, and 21% vs. 32% in year 3. Rates of endocarditis were similar between groups each year. No patients in either group developed structural valve deterioration requiring aortic valve replacement. Roughly 80% in each group had relief of symptoms.
Future efforts should aim to reduce procedure-related complications from TAVR, including strokes, vascular events, and paravalvular regurgitation, Dr. Thourani said.
"With a 44% mortality at 3 years, what we have to learn is how to select better patients," Dr. Bernard J. Gersh commented during a panel discussion of the findings. Dr. Gersh is professor of medicine at the Mayo Clinic, Rochester, Minn.
Experts in Europe have begun a series of meetings to try to define a transcatheter-specific risk score that might be a better gauge than the STS score in selecting patients for TAVR, Dr. Thourani said.
Patients in the current analysis have a minimum of 3 years of follow-up, so the findings really give a hint of 3- to 5-year results, Dr. Thourani said. "I think we can say something about the durability of these valves."
Dr. Patrick T. O’Gara cautioned against generalizing results from the PARTNER cohort, which averaged 84 years in age. "We have durability information in the octogenarian group over 3 years of time. When we think about deploying this kind of technology in younger and healthier individuals, there remain concerns about durability and about paravalvular leaks," he said at a press briefing.
Concerns about some findings, such as the 44% mortality rate at 3 years, may amount to unnecessarily "throwing darts" at the TAVR results, he suggested. "Let’s remember that we’re dealing with a group of patients who are 84 years of age on average. Our expectations for their outcomes need to be tempered by the context in which these procedures are offered," said Dr. O’Gara, director of clinical cardiology at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, Boston.
Each TAVR costs approximately $70,000-$75,000, Dr. Thourani estimated.
Edwards Lifesciences, which makes the transcatheter valve replacement systems, funded the PARTNER trial, and Dr. Thourani and some of his coinvestigators disclosed financial relationships with the company. He also disclosed relationships with St. Jude Medical, Marquet Medical, Sorin Medical, and Medtronic. Dr. O’Gara had nothing to disclose. Dr. Gersh disclosed financial relationships with St. Jude Medical and Boston Scientific.
Twitter @sherryboschert
AT ACC 13
Major finding: All-cause mortality rates after 3 years were 44% following TAVR and 45% following SAVR, with higher rates of valve leakage after TAVR and similar 3-year stroke rates between groups.
Data source: Three-year follow-up data on 699 elderly patients with aortic stenosis at high risk for surgery in the randomized, controlled PARTNER trial.
Disclosures: Edwards Lifesciences, which makes the transcatheter valve replacement systems, funded the PARTNER trial, and Dr. Thourani and some of his coinvestigators disclosed financial relationships with the company. He also disclosed relationships with St. Jude Medical, Marquet Medical, Sorin Medical, and Medtronic.
