Heart News and Notes

Doctors should not practice the medicine they learned decades ago in medical school. They are expected to participate in CME - continuing medical education. Oversight of CME is provided by the ACCME - the Accrediting Council for Continuing Medical Education.

Last year, every four-year medical school that offered ACCME-approved CME accepted commercial sponsorship for CME programs. But as of January 1, 2011, “to dispel the risk or appearance of conflict of interest,” the University of Michigan will no longer accept such industry support.

The ACCME itself has taken another step: CME presentations by drug industry employees will no longer be allowed at medical meetings. One of the affected meetings is the annual Scientific Sessions of the American Heart Association (AHA), and the AHA is fighting back against the ban.

Professional opinion is divided. Some believe the ban is counterproductive, while others think the ban should extend to doctors who receive industry support. One study cited in the controversy found that for every dollar a drug company spends on medical education it gets back $3.56 in revenue. Another found that attendees at industry-supported presentations did not perceive bias.

One of the challenges of writing these “Heart News and Notes” pages is deciding which news items to report on. Another is telling a consistent story when a study comes out with one conclusion and a month or two later another comes out with the opposite conclusion.

Now and then I report on a study that says some particular test, or test criterion, leads to better prediction of heart disease risk. But a few months ago I received news of a metastudy (a study of studies) that found that most of those studies were flawed, and overall the best risk predictor is still the old-fashioned Framingham score.

So it’s with some hesitation that I decided to tell you about a small pilot study that says ultrasound imaging of the heart and the carotid artery can reveal dangerous plaque in patients with a low Framingham risk score.

The study is inconclusive to begin with because it’s small, and because it was presented as an abstract without peer review. But within its limits it may be significant. It doesn’t require a complete echocardiogram. It applies only to women who are obese or have metabolic syndrome. Even if the Framingham score is best overall, there might be a subgroup that would benefit from ultrasound screening. Or this study might, after all, be a statistical fluke.

Rosiglitazone (Avandia) will be reconsidered by an FDA panel this month, July 13-14. Two more studies have found that this diabetes drug increases the risk of heart attack, stroke, heart failure and death compared with a related drug, pioglitazone (Actos). One author says if sixty patients are treated for a year with Avandia instead of Actos, one more will have a cardiovascular event. Other studies allege that the two drugs have the same risk. The American Heart Association and the American Diabetes Association say the evidence is insufficient, and patients should follow their doctors’ prescriptions.

Two new blood thinners have been getting “buzz” in journals and conferences. A new antiplatelet drug, ticagrelor (Brilanta), will be considered for approval by another panel on July 28. Clinical trials show it to be more effective against heart attack, stroke and cardiovascular death than the current standard, clopidogrel (Plavix).

A new anticoagulant, dabigatran (Pradax), reported to be more effective against stroke than warfarin (Coumadin), with less risk of bleeding, is expected to be considered by another FDA panel in September.

Now I am confused. A while back I looked into the glycemic index of foods, because high glycemic index means the carbohydrate is absorbed quickly and raises blood sugar, increasing the risk of diabetes. I saw statements like this: “Rice cooked too long will have an elevated glycemic response. Contrary to popular belief, brown rice does not have a lower glycemic index than white rice.”

But a recent study found that people who ate white rice five times a week had a higher risk of diabetes than those who ate less rice, while people who ate brown rice had lower risk. The authors thought people who ate brown rice (rice from which the bran and germ have not been removed) might have other healthy habits, and advised using whole grains with lower glycemic index than rice.

Dietary Guidelines for Americans 2010 have been issued for public comment (ending July 15). The guidelines are updated every five years by the Departments of Agriculture (USDA) and Health and Human Services (HHS). Final guidelines will be released by the end of the year.

The focus now is on the overweight and obese, because this group has become a majority. There is an emphasis on solid fats and sugars. Sugared beverages are to be “avoided,” not just “limited.” Moderate alcohol use is encouraged and daily multivitamins are discouraged.

Sodium, once limited to 2300mg, with a 1500mg target for at-risk groups, is now limited to 1500mg for everyone. Critics suggest that we figure out how to get down to 2300mg (which we haven’t got close to yet) before setting an even more ambitious goal.