This management study including consecutive outpatients suspected of having deep vein thrombosis of the legs shows that it is safe to withhold repeated ultrasound testing in patients with normal ultrasound and SimpliRED D-dimer test results at presentation. The combination of a low clinical pretest probability with either a normal compression ultrasound test or a normal D-dimer test result appears to be equally safe in refuting the diagnosis of deep vein thrombosis. Refuting the diagnosis on the basis of a normal compression ultrasound test result, a normal D-dimer test result, or a low clinical pretest probability alone is not safe.
There is so far only limited information on the effects of antithrombotic regimens on the incidence of angina pectoris. However, because angina is a powerful predictor of major events of coronary heart disease, these effects should be evaluated. Warfarin has an immediate effect on blood coagulability and thrombosis, and recent evidence suggests that it may exert some of its benefit through a delayed effect, perhaps on the vessel wall. The study by Knottenbelt et al provides some, though far from conclusive, support for a delayed effect and also suggests that low-dose aspirin may increase rather than reduce the incidence of angina. However, the value of aspirin in the prevention of nonfatal myocardial infarction is reemphasized, as is the benefit of combined treatment with low-intensity anticoagulation and aspirin in preventing both fatal and nonfatal events of coronary heart disease.
Anger can trigger myocardial ischemia. We examined the risk of premature and total cardiovascular disease (CVD) associated with anger during early adult life in a prospective study of 1055 men followed up to 48 years. A total of 205 men developed CVD, 77 before age 55 years (defined as premature disease). The highest level of anger in response to stress, compared with lower levels, was associated with an increased risk of premature CVD, including premature coronary heart disease and myocardial infarction, but not total CVD. Anger predicts incidence of premature CVD.
Mean concentrations of total cholesterol (TC) among adults have declined in the United States for decades. Whether the decline has been due to prevention of high TC levels or to treatment of high TC levels once present is not known. Goff et al examined changes in the entire distribution of TC levels across US birth cohorts as sampled in the National Health Examination Survey and the National Health and Nutrition Examination Surveys I, II, and III. Data were analyzed on 49 536 participants born between 1887 and 1975 and examined at ages 18 through 74 years between 1959 and 1994. The entire distribution of TC has shifted to lower concentrations during this period. This downward shift supports the contention that a strong prevention effect occurred in the US population during the period 1959 through 1994. Greater understanding of this dramatic change could support future cardiovascular disease prevention efforts.
Human immunodeficiency virus (HIV) testing efforts targeted to only symptomatic patients are inadequate to identify the one third of HIV-positive people in the United States who are unaware of their infection. In their study, Walensky et al implemented 1993 Centers for Disease Control and Prevention recommendations and offered routine HIV counseling and testing to inpatients in an urban Boston (Mass) hospital. This program identified nearly twice the number of HIV infections as background testing alone. Patients who were tested during the program, who would likely not have been tested if this initiative had not been in place, had an estimated HIV seroprevalence of 3.8% (95% confidence interval, 1.8%-5.8%). The authors have shown that offering voluntary, routine inpatient HIV counseling and testing can be successful as a screening program and in identifying a substantial number of patients with undiagnosed HIV infection who can be informed, counseled, and linked to care and treatment.
Dotted lines represent 95% upper and lower confidence intervals.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2002;162(8):863. doi:10.1001/archinte.162.8.863