Endocarditis infecciosa Profilaxis

Estudio que muestra la tendencia temporal de endocarditis infecciosa en una región determinada (Olmsted County) y el impacto de las nuevas indicaciones para profilaxis antibiótica de endocarditis del año 2007 en relación especialmente con los procedimientos dentales. En el año 2007 la American Heart Association (AHA) publicó la actualización de las guías para la prevención de la endocarditis infecciosa (EI) que restringía de forma importante el uso de la profilaxis antibiótica a un grupo de pacientes en riesgo sometidos a procedimiento dentales o invasivos de otro tipo. Los autores pretenden conocer la incidencia de EI debida al grupo de estreptococos tipo viridans (GEV) en los Estados Unidos tras la publicación de las guías de la AHA del 2007, hasta ahora no estudiada. Los métodos utilizados consistieron en la realización de una revisión basada en poblaciones de todos los casos definitivos o posibles de EI-GEV usando la base de datos conocida como Rochester Epidemiology Project of Olmsted County, Minnesota. Los datos demográficos y microbiológicos fueron recogidos para todos los casos de EI-GEV diagnosticados desde el 1 de enero de 1999 hasta el 31 de diciembre de 2010. Examinaron también la base de altas hospitalarias conocida como Nationwide Inpatient Sample (NIS) para determinar el número de casos de EI-GEV incluidos entre 1999 y 2009. Se identificaron 22 casos con EI-GEV en Olmsted County en un período de 12 años. Las tasas de incidencia (por 100.000 persona-años) durante los intervalos de tiempo de 1999-2002, 20032006, y 2007-2010, fueron 3,19 (intervalo de confianza [IC] 95% 1,20-5,17), 2,48 (IC 95% 0,85-4,10), y 0,77 (IC 95% 0,00-1,64), respectivamente (valor-p=0,061 mediante regresión de Poisson). El número de altas hospitalarias con el diagnóstico de EI-GEV en la base datos NIS durante 1999-2002, 2003-2006, y 2007-2009 osciló entre 15.318-15.938, 16.214-17.433, y 14.728-15.479, respectivamente. Los autores concluyen, basándose en los datos completos hasta 2010, que no se ha percibido un incremento en la incidencia de EI-GEV en Olmsted County, Minnesota tras la publicación en 2007 de las guías AHA de prevención de la EI. Comentario A pesar de los avances en el tratamiento médico, quirúrgico y cuidados críticos, la EI continúa siendo una enfermedad con riesgo de mortalidad. Por ello es altamente deseable la implementación de medidas efectivas de profilaxis. Debido al riego conocido de bacteriemia en intervenciones invasivas la AHA ha venido publicando recomendaciones formales sobre la profilaxis de EI desde el año 1955. A lo largo de los años, sin embargo, la evidencia acumulada ha venido sugiriendo que el riesgo de bacteriemia durante procedimientos invasivos dentales no es sustancialmente mayor que con las actividades de la vida diaria. Debido a la disponibilidad de estos datos y otros más, recientemente publicados, la AHA decidió realizar cambios radicales en las guías de prevención de EI del 2007, dejando la recomendación de profilaxis antibiótica para las intervenciones dentales invasivas en únicamente 4 grupos de pacientes que presentarían un mayor riesgo de complicaciones y mortalidad si desarrollarán una endocarditis; por otro lado, las guías de 2007 dejaron de recomendar antibióticos para la prevención de EI antes de procedimientos invasivos gastrointestinales y genitourinarios. Estos 4 grupos serían: Pacientes con válvulas protésicas o material protésico por reparación valvular, pacientes con una EI previa, pacientes con una cardiopatía congénita (cianótica no reparada, defecto reparado completamente con material protésico los primeros seis meses, defecto reparado con defectos residuales) y receptores de transplante cardiaco con regurgitación valvular por anomalía estructural en dicha válvula. Obviamente es un estudio con limitaciones propias de un modelo de casos y controles como el escaso tamaño muestral, sesgos, demografía no representativa, la imperfección y las bases utilizadas. En un editorial acompañante al artículo, Peter B. Lockhart afirma que las recomendaciones cubren un 10% de las personas en riesgo, dejando al riesgo moderado que era un 90% de los casos sin indicación de profilaxis. El editorialista muestra datos interesantes que han justificado el porqué de una menor indicación de la profilaxis como que la bacteriemia transitoria frecuentemente se produce como resultado de la acumulación de placa dental, que evoluciona a una capa densa de bacterias orales que se sitúan alrededor de los dientes y que cruzan la inflamación periodontal para pasar a acantonarse en la circulación, es claro que esta debe ser la fuente principal y puerta de entrada para bacterias orales que causan más de un 25% de los casos de EI de origen comunitario.  La ciencia actual sugiere con fuerza que la mala higiene oral y la enfermedad periodontal son mucho mayores factores de riesgo para el desarrollo de EI por bacterias orales que los procedimientos dentales invasivos. El estudio más grande hasta la fecha que ha comparado el cepillado de dientes (fuente de origen natural de la bacteremia) con la extracción dental (un procedimiento dental altamente invasivo), encontró que la incidencia de bacteriemia del cepillado de dientes (32%) fue lo suficientemente alta como para sugerir fuertemente que la bacteriemia a partir de diversas actividades de la vida diaria (masticación de los alimentos también) puede ocurrir cientos de veces más que la bacteriemia a partir de procedimientos dentales invasivos; este estudio además proporciona una documentación única de una fuerte asociación entre parámetros de higiene oral-enfermedad gingival y la incidencia de bacteriemia por especies relacionadas con EI. El estudio de DeSimone y colaboradores ha suministrado datos adicionales para reforzar la tendencia observada hacia un menor número de pacientes cardiacos que precisan profilaxis antibiótica, y supone un apoyo a realizar un estudio más completo que permita determinar el grado en que la higiene oral, enfermedad periodontal y las bacterias orales se asocian con la EI adquirida en la comunidad. Referencia Incidence of Infective Endocarditis due to Viridans Group Streptococci Before and After Publication of the 2007 American Heart Association's Endocarditis Prevention Guidelines Daniel C. DeSimone, Imad M. Tleyjeh, Daniel D. Correa de Sa, Nandan S. Anavekar, Brian D. Lahr, Muhammad R. Sohail, James M. Steckelberg, Walter R. Wilson y Larry M. Baddour doi: 10.1161/​CIRCULATIONAHA.112.09528.

Published with Blogger-droid v2.0.3

Stents medicados, beneficios comparados con metalicos puros

TUESDAY Aug. 21, 2012 -- A newer generation, drug-releasing stent led to fewer adverse cardiac events, such as heart-related death or heart attack linked to the same artery, than bare metal stents did among heart attack patients, a new study shows. Stents are tiny mesh tubes surgically implanted to open arteries. Swiss researchers noted the newer drug-emitting stents may also help patients avoid the chronic inflammation associated with early-generation drug-releasing stents. "Newer-generation drug-eluting stents with biodegradable polymers provide controlled drug release," the study authors explained in the Aug. 22/29 issue of the Journal of the American Medical Association. Led by Dr. Lorenz Raber, of Bern University Hospital, the research team compared the safety and effectiveness of stents that released the drug biolimus from a biodegradable polymer, against bare metal stents that did not release a drug. The study involved almost 1,200 patients in Europe and Israel who had a type of heart attack known as ST-segment elevation myocardial infarction (STEMI). Nearly 80 percent of the patients were men, and the average age was 61 years. The participants were randomly assigned to receive the drug-releasing stent or the bare metal stent. They were examined one month after their artery opening procedure, and again at 12 months. The researchers determined the effectiveness of the stents by measuring rates of adverse cardiac events, including cardiac death and other heart problems. The investigators found that at one year, 4.3 percent of patients who received the drug-releasing stents experienced major adverse cardiac events, compared to 8.7 percent of patients who received bare metal stents. These findings represent a significant 4.4 percent absolute reduction and 51 percent relative reduction in the risk for major adverse cardiac events, the researchers pointed out in a journal news release. Use of the new drug-releasing stent also resulted in reduced risk for cardiac death. At one year, rates of clotting within the stent were about 1 percent among patients with the drug-releasing stents, compared to just over 2 percent among patients who received bare metal stents. "Our results suggest better clinical outcomes in terms of major adverse cardiac events of a stent releasing biolimus from a biodegradable polymer compared with a bare metal stent for the treatment of patients with STEMI," the study authors concluded. Another expert agreed. "Newer generation drug-eluting stents which are currently FDA-approved in the United States have been shown to be superior to bare metal stents in decreasing event rates at one year when used for [heart attack]," said Dr. Barry Kaplan, vice chairman of cardiology at North Shore University Hospital in Manhasset, N.Y. "This trial is further proof that drug-eluting stents used in heart attack patients lead to superior results," he added. And Kaplan noted that, compared to bare metal stents, the drug-releasing models had fewer dangerous events at one year, including re-closure of the artery or clotting within the stent. But, he added one caveat. "The relative comparison between the biolimus-coated stent used in this study versus [other] currently available second-generation drug-eluting stents [available in the United States] still needs to be determined," Kaplan said.

Published with Blogger-droid v2.0.3

Hormone therapy and health consecuences in post menopausal women

August 16, 2012
Hormone therapy decreases risk of osteoporosis in post menopausal women, but may increase breast cancer risk
Authors <> Marjoribanks J, Farquhar C, Roberts H, Lethaby A
Review Group <> Menstrual Disorders and Subfertility Group
Abstract <> Hormone therapy (HT) is widely used for controlling menopausal symptoms and has also been used for the management and prevention of cardiovascular disease, osteoporosis and dementia in older women. This is an updated version of a Cochrane review first published in 2005.
Objectives:
To assess the effects of long term HT on mortality, cardiovascular outcomes, cancer, gallbladder disease, fractures, cognition and quality of life in perimenopausal and postmenopausal women, both during HT use and after cessation of HT use.
Search methods:
We searched the following databases to February 2012: Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO.
Selection criteria:
We included randomised double-blind studies of HT versus placebo, taken for at least one year by perimenopausal or postmenopausal women. HT included oestrogens, with or without progestogens, via oral, transdermal, subcutaneous or intranasal routes.
Data collection and analysis:
Two authors independently assessed study quality and extracted data. We calculated risk ratios (RRS) for dichotomous data and mean differences (MDs) for continuous data, with 95% confidence intervals (CIs). Where findings were statistically significant, we calculated the absolute risk (AR) in the intervention group (the overall risk of an event in women taking HT).
Results:
Twenty-three studies involving 42,830 women were included. Seventy per cent of the data were derived from two studies (WHI 1998 and HERS 1998). Most participants were postmenopausal American women with at least some degree of co-morbidity, and the mean participant age in most studies was over 60 years. None of the studies focused on perimenopausal women. In relatively healthy postmenopausal women (that is generally fit, without overt disease) combined continuous HT significantly increased the risk of a coronary event (after one year's use: AR 4 per 1000, 95% CI 3 to 7), venous thrombo-embolism (after one year's use: AR 7 per 1000, 95% CI 4 to 11), stroke (after three years' use: AR 18 per 1000, 95% CI 14 to 23), breast cancer (after 5.6 years' use: AR 23 per 1000, 95% CI 19 to 29), gallbladder disease (after 5.6 years' use: AR 27 per 1000, 95% CI 21 to 34) and death from lung cancer (after 5.6 years' use plus 2.4 years' additional follow-up: AR 9 per 1000, 95% CI 6 to 13). Oestrogen-only HT significantly increased the risk of venous thrombo-embolism (after one to two years' use: AR 5 per 1000, 95% CI 2 to 10; after 7 years' use: AR 21 per 1000, 95% CI 16 to 28), stroke (after 7 years' use: AR 32 per 1000, 95% CI 25 to 40) and gallbladder disease (after seven years' use: AR 45 per 1000, 95% CI 36 to 57) but did not significantly increase the risk of breast cancer. Among women aged over 65 years who were relatively healthy and taking continuous combined HT, there was a statistically significant increase in the incidence of dementia (after 4 years' use: AR 18 per 1000, 95% CI 11 to 30). Among women with cardiovascular disease, long term use of combined continuous HT significantly increased the risk of venous thrombo-embolism (at one year: AR 9 per 1000, 95% CI 3 to 29). Women taking HT had a significantly decreased incidence of fractures with long term use (after 5.6 years of combined HT: AR 86 per 1000, 95% CI 79 to 84; after 7.1 years' use of oestrogen-only HT: AR 102 per 1000, 95% CI 91 to 112). Risk of fracture was the only outcome for which there was strong evidence of clinical benefit from HT. There was no strong evidence that HT has a clinically meaningful impact on the incidence of colorectal cancer. One trial analysed subgroups of 2839 relatively healthy 50 to 59 year old women taking combined continuous HT and 1637 taking oestrogen-only HT versus similar-sized placebo groups. The only significantly increased risk reported was for venous thrombo-embolism in women taking combined continuous HT: their absolute risk remained low, at less than 1/500. However, other differences in risk cannot be excluded as this study was not designed to have the power to detect differences between groups of women within 10 years of the menopause.
Authors' conclusions:
HT is not indicated for primary or secondary prevention of cardiovascular disease or dementia, nor for preventing deterioration of cognitive function in postmenopausal women. Although HT is considered effective for the prevention of postmenopausal osteoporosis, it is generally recommended as an option only for women at significant risk, for whom non-oestrogen therapies are unsuitable. There are insufficient data to assess the risk of long term HT use in perimenopausal women or postmenopausal women younger than 50 years of age.
Implications <>
Implications for practice:
HT for women with menopausal symptoms Women who find menopausal symptoms intolerable and who are at low risk of cardiovascular disease, venous thrombo-embolism or breast cancer may wish to weigh the benefits of symptom relief against the small absolute risk of harm arising from short term use. Current recommendations favour the use of low dose HT for relief of vasomotor syptoms among women within 10 years of their last period, taken for the shortest possible time required to achieve treatment goals, with doses individually tailored and reviewed regularly (NAMS 2010; RANZCOG 2011; Taylor 2011). Although none of the studies included in this review focused specifically on women in the age group most likely to require menopausal symptom relief, subgroup analyses in WHI 1998 suggested that among relatively healthy women in their 50s taking oestrogen-only or combined HT, the only significant risk was increased incidence of venous thrombo-embolism in those taking combined HT. The absolute risk of venous thrombo-embolism was low, at 0.5% overall for a woman taking HT for five years. For women in their 50s without a uterus, taking oestrogen-only HT for five to six years appears relatively safe and there may even be some health benefits; however, safety over longer term use is unknown. Additional risk factors such as a history of venous thrombosis or known increased risk of thrombo-embolic disease must also be considered when deciding whether likely symptom relief from HT outweighs potential harm. The risk of endometrial cancer for women with a uterus taking oestrogen-only HT is well documented. HT for other indications Hormone therapy may have a limited role in the treatment of osteoporosis for some women, but there is no evidence that any form of HT is beneficial for other clinical indications except menopausal symptom relief, nor is HT appropriate for the prevention of chronic disease. There is strong evidence that both oestrogen-only HT and combined therapy significantly increase the risk of stroke and gallbladder disease and that long term use of combined continuous therapy also increases the risk of coronary events, breast cancer, death from lung cancer and (in women aged over 65 years) dementia. HT for women with previous disease or smoking history HT is not recommended for use in women with cardiovascular disease (HERS 1998) or with a history of venous thrombosis (EVTET 2000) or breast cancer (Chlebowski 2004; Holmberg 2008; ICR 2001). The randomised evidence provides no specific contraindications for its use in women with a history of endometrial cancer (Barakat 2006) or ovarian cancer (Guidozzi 1999), though data are scanty. Women at high risk of lung cancer (current smokers or long term past smokers) should be aware that combined HT increases the risk of death from lung cancer.
Implications for research:
No studies have adequately assessed the safety of HT used for symptom relief for perimenopausal women, women aged under 50 years or women with temporary or permanent iatrogenic ovarian failure. Not enough is known about factors that may modulate the risks involved, such as clinical characteristics or biomarkers affecting individual women, different oestrogens and progestogens, different time-frames for the use of HT, and different doses and routes of administration (for example unopposed oestrogen and intrauterine progestogen). There is also a pressing need for reliable evidence on the efficacy and safety of alternatives to HT for the control of menopausal symptoms for those women who may wish to avoid using HT or for whom it is unsuitable.

Lipid-altering efficacy of ezetimibe plus statin and statin monotherapy and identification of factors associated with treatment response: A pooled ana

Atherosclerosis. 2012 Aug

Morrone D, Weintraub WS, Toth PP, Hanson ME, Lowe RS, Lin J, Shah AK, Tershakovec AM.

Source

Cardiology Section, Christiana Care Health System, Newark, DE, United States.

Abstract

OBJECTIVE:

Patients with dyslipoproteinemia constitute the largest risk group for development of atherosclerosis and cardiovascular disease (CVD). Despite extensive statin use, many patients with CVD risk do not achieve guideline-recommended low-density lipoprotein cholesterol (LDL-C) targets. This pooled analysis of 27 previously published clinical trials conducted between 1999 and 2008 evaluated the lipid-altering efficacy and factors related to treatment response of ezetimibe combined with statin and statin monotherapy.

METHODS:

Patient-level data were combined from double-blind, placebo-controlled or active comparator studies randomizing adult subjects to ezetimibe 10mg plus statin (n=11,714) versus statin alone (n=10,517) for 6-24 weeks (mean=9 weeks). Association of factors with treatment response, percent change from baseline LDL-C and other lipids, and attainment of guideline-recommended lipid and lipoprotein targets were evaluated.

RESULTS:

Higher baseline LDL-C, diabetes mellitus, Black race, greater age, and male gender were associated with small but significantly greater percent reductions in LDL-C regardless of treatment. Treatment influenced efficacy, with ezetimibe plus statin producing significantly greater reductions in LDL-C, total-cholesterol, non-HDL-C, ApoB, triglycerides, lipid ratios, hs-CRP; significantly larger increases in HDL-C and ApoA1; and significantly higher achievement of LDL-C (<70mg/dl, <100mg/dl), non-HDL-C (<100mg/dl, <130mg/dl), and ApoB (<80mg/dl, <90mg/dl) targets than statin monotherapy at statin potencies compared (p<0.0001 for all). Differential treatment effects were seen with first-/second-line therapy and statin potency.

CONCLUSION:

These results suggest that patient characteristics have a limited influence on response to lipid-lowering therapy and demonstrate the consistent treatment effect of ezetimibe combined with statin and statin monotherapy across a diverse patient population.

Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.