Digoxina en Fibrilacion auricular y aumento de mortalidad

Heart Drug Digoxin Tied to Higher Death Risk for Some Patients Study found increased mortality for people with atrial fibrillation, an irregular heartbeat Wednesday, November 28, 2012 WEDNESDAY, Nov. 28 (HealthDay News) -- The widely used heart drug digoxin is associated with an increased risk of death in people with the common heart rhythm disorder know as atrial fibrillation, a new study finds. Researchers analyzed data from more than 4,000 patients with atrial fibrillation and found that digoxin was associated with a 41 percent increased risk of death from all causes, a 35 percent increased risk of death from cardiovascular causes, and a 61 percent increased risk of death from problems with the rate and rhythm of the heartbeat. The findings mean that among patients with atrial fibrillation who take taking digoxin -- compared to those not taking digoxin -- one additional patient out of six will die from any cause over five years, one additional patient out of eight will die from cardiovascular causes, and one additional patient out of 16 will die from arrhythmias, the study authors said. The study, led by Samy Claude Elayi, an associate professor of medicine at the Gill Heart Institute at the University of Kentucky, was published online Nov. 28 in the European Heart Journal. Digoxin is found naturally in the foxglove plant, from which it is extracted. The drug helps the heart beat more strongly and with a more regular rhythm and is commonly used in both atrial fibrillation patients and heart failure patients. However, while the use of digoxin has been widely studied in heart failure patients, there's been a lack of data about its use in patients with the irregular heartbeat, according to the study authors. They said their findings call into the question the widespread use of digoxin in atrial fibrillation patients. "These findings mean that physicians should try to control a patient's heart rate by using alternatives as a first line, such as beta-blockers or calcium blockers; if digoxin is used, use a low dose with careful clinical follow-up, evaluate potential drug interactions when starting new medications, and monitor digoxin levels," the authors said "Patients should be aware of potential toxicity and see their physicians immediately in specific clinical situations, for instance if they experience palpitations or syncope (fainting), as those may precede arrhythmic death," they added. The mechanism by which digoxin increased the risk of death in atrial fibrillation patients is unclear. And while the study noted an association between digoxin use and increased death risk in these patients, it could not prove a cause-and-effect relationship. "Deaths from classic cardiovascular causes, whether due to arrhythmia or not, can partly but not entirely explain [the relationship]," Elayi and his colleagues wrote. "This suggests there must be some additional mechanism that remains to be identified." SOURCE: European Heart Journal, news release, Nov. 28, 2012 Copyright (c) 2012 ScoutNews, LLC. All rights reserved.

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Toronja y otros interactuan con tratamiento medico Alerta

Un estudio halla que cada vez hay más medicamentos que no combinan bien con el pomelo El número de fármacos potencialmente arriesgados ha aumentado más del doble en cuatro años Envíelo a un amigo Traducido del inglés: martes, 27 de noviembre, 2012 LUNES, 26 de noviembre (HealthDay News) -- A causa de las nuevas formulaciones químicas, el número de medicamentos recetados que no combinan bien con el pomelo se ha incrementado en más del doble desde 2008, aunque muchos médicos no son conscientes de esto, informan investigadores canadienses. "El número de medicamentos a la venta con posibilidades de provocar efectos adversos graves y que en muchos casos pueden costar la vida al interactuar con el pomelo ha aumentado notablemente en los últimos años, de 17 a 43 en cuatro años", aseguró el investigador principal David Bailey, del Instituto de Investigación sobre Salud Lawson en London, Ontario. "Hay mucha más necesidad de que los profesionales de atención a la salud entiendan las interacciones entre los medicamentos y el pomelo, que pongan en práctica esta información y que así el uso de estos medicamentos resulte seguro en la práctica clínica", señaló Bailey. Incluso pequeñas cantidades de pomelo o de jugo de pomelo, al interactuar con estos medicamentos, pueden causar una muerte súbita, insuficiencia renal aguda, problemas respiratorios, hemorragia gastrointestinal y otros efectos secundarios graves. Entre ellos están los medicamentos que bajan el colesterol, los usados para la presión arterial, los del tratamiento del cáncer y antibióticos como la eritromicina, añadieron los investigadores. Según el artículo de revisión, publicado el 26 de noviembre en la revista Canadian Medical Association Journal, más de 85 medicamentos pueden interactuar con el pomelo. 43 de estos medicamentos pueden causar efectos secundarios graves, advirtieron los investigadores. Los productos cítricos como las limas y las naranjas amargas, a menudo usadas en la mermelada, también contienen ingredientes activos (llamados furanocumarinas) que provocan interacciones peligrosas, según los investigadores. Al parecer, estas sustancias químicas inhiben una enzima que normalmente desactiva alrededor de la mitad de los efectos de la medicación. Todos los medicamentos que interactúan con estas sustancias químicas se toman oralmente y no se metabolizan adecuadamente, lo que significa que el medicamento pasa por el cuerpo sin entrar en el torrente sanguíneo. Todos se metabolizan en el estómago del mismo modo, indican los investigadores. Una pequeña cantidad de pomelo, aunque se ingiera horas antes de tomar los medicamentos, puede aumentar la cantidad del medicamento metabolizado, con lo que es como si se tomaran muchas dosis a la vez, de acuerdo con los investigadores. El efecto tóxico puede crecer cuando se toma el medicamento de forma repetida. Por ejemplo, si el Zocor, un medicamento para bajar el colesterol, se combina con un vaso de siete onzas de jugo de pomelo una vez durante tres días, la presencia del medicamento en el torrente sanguíneo aumentará un 330 por ciento, aseguró Bailey. Según el informe, estos son algunos de los medicamentos que pueden interactuar con el pomelo: Ciertos medicamentos con estatinas para bajar el colesterol, como el Zocor (simvastatina), el Lipitor (atorvastatina) y el Pravachol (pravastatina); Algunos medicamentos para bajar la presión arterial, como la nifedipina (Nifediac y Afeditab); Los fármacos contra el rechazo que se administran tras los trasplantes de órganos, como la ciclosporina (Sandimmun y Neoral), y Ciertos medicamentos cardiovasculares, como la amiodarona (Cordarone y Nexterone), el clopidogrel y el apixaban. Las personas mayores de 45 años son las que más compran pomelo y tienen más probabilidades que los más jóvenes de tomar varios medicamentos, por lo que tienen un mayor riesgo. Además, son más vulnerables a las reacciones adversas de las interacciones entre los medicamentos y el pomelo debido a su edad avanzada, indicaron los investigadores. El Dr. Gregg Fonarow, vocero de la Asociación Americana del Corazón (American Heart Association) y profesor de cardiología en la Universidad de California, en Los Ángeles, aseguró que se sabe poco sobre la frecuencia con la que estos efectos adversos se producen en la práctica real. Se necesitan más estudios, añadió. "A los pacientes que toman medicamentos que puedan entrar en interacciones adversas graves se les debería advertir, en general, que evitaran tomar pomelo, en cantidades moderadas o grandes, o que hablaran con su médico sobre qué medicamentos alternativos podrían tomar que no sean metabolizados debido a la enzima del hígado inhibida por el pomelo", afirmó Fonarow. Artículo por HealthDay, traducido por Hispanicare FUENTES: David Bailey, Ph.D., Lawson Health Research Institute, London, Ontario, Canada; Gregg Fonarow, M.D., spokesman, American Heart Association, professor of cardiology, University of California, Los Angeles; Nov. 26, 2012, Canadian Medical Association Journal (c) Derechos de autor 2012, ScoutNews, LLC

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Ejercicio estatinas dieta y baja mortalidad cardiovascular

Statins Plus Exercise Best at Lowering Cholesterol, Study Finds Moderate exercise reduced death risk even without drugs Tuesday, November 27, 2012 TUESDAY, Nov. 27 (HealthDay News) -- People who exercise along with taking statins to lower their high cholesterol levels can dramatically reduce their risk of dying, a large new study suggests. "The reduction in death is independent; whatever statins do is independent of what exercise does," said lead researcher Peter Kokkinos, a professor in the cardiology department at the Veterans Affairs Medical Center in Washington, D.C. "When you combine the two, you get even better results," he said. "If you are taking statins, your mortality is about 35 percent lower versus not taking statins, but if you exercise, your mortality level decreases as your fitness level increases to the point where you can reach a 70 percent reduction in mortality." Kokkinos is talking about regular moderate exercise -- not vigorous workouts. "Thirty minutes a day of brisk walking -- not a whole lot," he said. Statin drugs include Lipitor (atorvastatin), Lescol (fluvastatin), Pravachol (pravastatin), Crestor (rosuvastatin) and Zocor (simvastatin). Some people can't take statins because of side effects, Kokkinos said. "For these people, exercise alone reduces your risk just as much, if not more, than statins," he said. However, he stressed, "we do not recommend that people do not take their statins." Exercise works by stressing the body making it stronger, Kokkinos said. It's an evolutionary adaptation to protect the body from being overcome by changing stressors, he said. "Get off the couch -- walk," Kokkinos said. "About 150 minutes a week of brisk walking is all you need." The report was published online in the Nov. 28 edition of The Lancet. For the study, Kokkinos' team analyzed the medical records of more than 10,000 veterans with high cholesterol levels treated in Veterans Affairs hospitals in Washington D.C., and Palo Alto, Calif. Of these, 9,700 were men and 343 were women. The researchers judged the fitness levels of the participants by looking at the results of standard treadmill exercise tolerance tests, which were given between 1986 and 2011. Fewer deaths occurred among participants who were taking statins and were physically fit. Over 10 years of follow-up, those who were the most physically fit had the lowest risk of dying, the researchers noted. These fittest people actually reduced their risk of dying by about 60 percent regardless of whether they were taking statins, according to the study. These difference in death risk could not be explained by age, weight, ethnicity, gender, history of cardiovascular disease, risk factors for cardiovascular disease or medications, the researchers said. According to the U.S. Centers for Disease Control and Prevention, about 71 million Americans have high cholesterol, which is an important risk factor for heart disease, the authors pointed out. One expert familiar with the new findings cautioned that exercise is not a replacement for statins in those with high cholesterol. The best results are among those taking statins and who are the fittest, he emphasized. "Cardiovascular disease remains the leading cause of death and disability in men and women in the United States," said Dr. Gregg Fonarow, a spokesman for the American Heart Association and a professor of cardiology at the University of California, Los Angeles. "Statin therapy has been proven in multiple clinical trials to substantially reduce cardiovascular events and all-cause mortality in men and women with or at risk for cardiovascular disease," he said. Some people have assumed that if they are engaging in regular exercise and are physically fit that they may not benefit from statin treatment and some physicians consider statin therapy only for patients who have failed attempts at lifestyle modification, Fonarow said. This new study shows that at all levels of physical fitness, statin therapy was independently associated with lower risk of dying. The very best 10-year outcomes were among men and women taking statins with the highest fitness levels, he noted. "These findings further reinforce the remarkable real-world clinical effectiveness and safety of statin therapy to prevent and treat cardiovascular disease," Fonarow said. SOURCES: Peter Kokkinos, Ph.D., professor, Veterans Affairs Medical Center, Washington, D.C.; Gregg Fonarow, M.D., spokesman, American Heart Association, and professor, cardiology, University of California, Los Angeles; Nov. 28, 2012, The Lancet, online Copyright (c) 2012 ScoutNews, LLC. All rights reserved. Top | Home | Contact Us | Copyright | Privacy National Library of Medicine | National Institutes of Health | Department of Health and Human Services Page last updated on: 28 November 2012

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Fracturas en personas con osteoporosis a pesar del tratamiento adecuado

Abrahamsen B, Rubin KH, Eiken PA, Eastell R; Osteoporosis International (Oct 2012) Antiresorptive treatment reduces the risk of fractures, but most patients remain at elevated risk. We used health registers to identify predictors of new major osteoporotic fractures in patients adhering to alendronate. Risk factors showed a different pattern than in the general population and included dementia, ulcer disease, and Parkinson's disease. INTRODUCTION: Antiresorptives reduce the excess risk of fractures in patients with osteoporosis, but most patients remain at elevated risk. In some countries, patients must sustain fractures while on bisphosphonate (BP) treatment to qualify for more expensive treatment. It is unclear if patients who fracture on BP can be viewed as a distinct subgroup. METHODS: The National Prescription registry was used to identify 38,088 new alendronate users. The outcome was major osteoporotic fractures 6+ months after filling the first prescription in patients with a medication possession ratio>80 %. RESULTS: One thousand and seventy-two (5.5 %) patients sustained major osteoporotic fractures. The risk increased with age and was lower in men. The most important risk factor was the number of comedications (hazard ratio (HR) 1.04, 95 % CI 1.03-1.06, for each drug). Dementia (HR 1.81, 95 % CI 1.18-2.78), prior fracture (one: HR 1.17, 95 % CI 1.02-1.34; multiple: HR 1.34, 95 % CI 1.08-1.67), and ulcer disease (HR 1.45, 95 % CI 1.04-2.03) also increased the risk. Diabetes did not influence fracture risk, nor did rheumatic disorders. The risk was lower in glucocorticoid users (HR 0.78, 95 % CI 0.65-0.93). CONCLUSION: Risk factors while adhering to BP show a somewhat different pattern than that of the general population and FRAX. Ulcer disease and dementia may impair the ability to use the medications correctly. Though this is an observational study and associations may not be causal, it may be prudent to include dementia, ulcer disease, and Parkinson's disease to capture the risk of fractures on treatment. Lower risk in patients treated with glucocorticoids and in men probably reflects a lower treatment threshold related to guidelines.

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Antiplatelet therapy and proton pump inhibition: cause for concern?

Source: Curr Opin Cardiol 

Depta JP, Bhatt DL; Current Opinion in Cardiology 27 (6), 642-50 (Nov 2012)

PURPOSE OF REVIEW To review the current evidence on the clinical significance of the drug-drug interactions between the available antiplatelet agents and proton pump inhibitors (PPIs). RECENT FINDINGSGastrointestinal bleeding is associated with higher rates of morbidity and mortality following a myocardial infarction. PPIs are commonly used to prevent gastrointestinal bleeding. PPIs can attenuate metabolism of clopidogrel to its active metabolite by inhibiting various hepatic CYP450 enzymes, mainly CYP2C19. Concomitant use of a PPI with clopidogrel reduces clopidogrel active metabolite generation and subsequent platelet inhibition. In observational studies, the clinical significance of this drug-drug interaction is mixed. Evidence from the only randomized trial studying the clinical implications of the PPI-clopidogrel interaction did not demonstrate any difference in cardiovascular outcomes but did show a reduction in gastrointestinal bleeding with use of a PPI. SUMMARYThe drug-drug interaction between antiplatelet agents and PPIs at the enzymatic level does not seem to result in worse clinical outcomes. The risk of gastrointestinal bleeding with antiplatelet therapy is substantial. Clinicians should use PPIs in selected high-risk patients to prevent gastrointestinal bleeding.