Guidelines for elective percutaneous coronary intervention (PCI) for patients with stable coronary artery disease specify that myocardial ischemia should be documented on noninvasive testing before patients undergo elective PCI. In an analysis of 2004 Medicare claims data, Lin and colleagues Article determined the frequency and predictors of stress testing prior to elective PCI. The authors found that only 44.5% of the patients had stress testing within 90 days before elective PCI, and the authors report wide variation in rates of stress testing before PCI across geographic regions and across patient and physician characteristics. In an editorial, Diamond and Kaul Article discuss the effectiveness of PCI and anti-ischemic medical therapy and elaborate on the discord between practice guidelines and clinical practice.
Elevated homocysteine levels have been associated with dementia and Alzheimer disease; however, evidence that homocysteine reduction can slow the rate of cognitive decline in persons with Alzheimer disease is inconclusive. In a randomized trial involving patients with mild to moderate Alzheimer disease and normal levels of folic acid, B12, and homocysteine at baseline, Aisen and colleagues Article investigated the effect of high-dose supplementation with folate (5 mg/d), vitamin B6 (25 mg/d), and vitamin B12 (1 mg/d) vs placebo on cognitive decline. The authors report that patients receiving high-dose B vitamin supplementation had a significant reduction in homocysteine levels but similar rates of cognitive decline as patients receiving placebo during the 18-month study. In an editorial, Clarke and Bennett Article discuss the evidence linking elevated homocysteine levels with dementia and review the lack of evidence that lowering homocysteine levels prevents or slows cognitive decline.
Amiodarone is an effective therapy for long-term prevention of atrial fibrillation (AF) but is associated with significant adverse events. In a randomized trial of patients with recurrent AF, Ahmed and colleagues tested the hypothesis that episodic amiodarone treatment—wherein amiodarone is discontinued after a month of sinus rhythm following electrical cardioversion and restarted if AF recurs—would be associated with fewer adverse events compared with continuous amiodarone treatment. The authors report that compared with patients who received continuous amiodarone, patients who received episodic amiodarone treatment had similar rates of a composite outcome of amiodarone-related and major cardiac adverse events but increased rates of AF recurrence, all-cause mortality, and cardiovascular hospitalizations.
In a systematic literature review of prospective studies involving adult patients with lower gastrointestinal tract symptoms, Ford and colleagues assessed the accuracy of individual symptoms and combinations of findings (Manning and Rome criteria, Kruis scoring system) to identify patients with irritable bowel syndrome. The authors found that individual symptoms had poor diagnostic accuracy and combinations of findings included in the diagnostic criteria and statistical models designed to distinguish irritable bowel syndrome from organic lower gastrointestinal tract diseases had only modest accuracy.
“In the maternity room, Sarah is flanked by her mother, who looks like she is about to burst into tears as she clutches Sarah's hand.” From “Babies Having Babies.”
HIV/AIDS experts agree that antiretroviral therapy and other prevention strategies are needed to control a pandemic in which efforts to expand treatment worldwide are outpaced by new infections.
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Join Rita F. Redberg, MD, MSc, November 19 from 2 to 3 PM eastern time to discuss stress testing to document ischemia before PCI. To register, go to http://www.ihi.org/AuthorintheRoom.
How would you manage an 82-year-old woman with hypertension and renal artery stenosis? Go to www.jama.com, read the case, and submit your response by October 29.
Theme Issue on the Health of the Nation
For your patients: Information about cardiac stress testing.
This Week in JAMA . JAMA. 2008;300(15):1729. doi:10.1001/jama.300.15.1729