Should We Set a Higher Bar for Coronary Angiography?

Compared with Ontario, obstructive disease is less common in patients who undergo catheterization in New York.

A recent study indicated that more cardiac catheterizations are performed per capita in New York State than in Ontario, Canada). Now, the same investigators have compared the prevalence of obstructive coronary artery disease (CAD) — defined as diameter stenosis ≥50% in the left main or ≥70% in a major epicardial vessel — in patients undergoing the procedure in the two regions.

Obstructive CAD was found in significantly more of approximately 55,000 patients undergoing a first elective cardiac catheterization during 2008–2011 in Ontario than in some 18,000 such patients in New York (45% and 30%, respectively). Compared with the Canadian patients, the New Yorkers were younger and more likely to be women or to have no or atypical symptoms; the prevalence of several other risk factors also differed significantly between the two groups. Fewer patients in New York than in Ontario had noninvasive evaluations (63% vs. 75%, P<0.001), and the predicted preprocedure probability of obstructive CAD was significantly lower in New York.

Among patients with obstructive CAD, those in New York were significantly more likely than those in Ontario to undergo revascularization (percutaneous coronary intervention, 55% vs. 35%; coronary artery bypass grafting, 20% vs. 14%). Higher crude 30-day mortality in New York than in Ontario was mainly attributable to higher mortality in patients without obstructive CAD.


These findings suggest that the relatively high cardiac catheterization rate in New York results primarily from selecting patients at lower predicted probabilities of obstructive coronary artery disease. The investigators could not control for regional differences in patient, societal, and physician characteristics, preferences, and expectations; nor could they assess which catheterization rate is more appropriate. Nonetheless, the higher prevalence of interventionalists and cardiac invasive capabilities — as well as market-oriented financing — in New York seems likely to account for much, if not all, of the disparity; if so, these data illuminate an opportunity to reduce unnecessary healthcare expenditures.

Source: NEJM

Invasive Management of ACS: The Kidneys Are All Right.

Despite early increases in acute kidney injury, invasive treatment is associated with better long-term outcomes than conservative management.
Invasive treatment options for acute coronary syndromes (ACS) might be underused in patients at high risk for renal disease because of concerns about contrast-induced renal failure and other complications. However, comparative data on renal outcomes in patients managed invasively versus conservatively are lacking. Therefore, investigators conducted a cohort study involving 10,516 patients presenting with non-ST-segment-elevation ACS in Alberta, Canada, 41% of whom received early invasive management (coronary catheterization within 2 days after hospital admission). Stratification according to baseline estimated glomerular filtration rate and propensity-score matching resulted in a cohort of 6768 participants.

Compared with conservative management, early invasive therapy was associated with an increased risk for acute renal injury (10.3% vs. 8.7%, P=0.019), but treatments did not differ in risk for dialysis (0.4% vs. 0.3%, P=0.670) during the index hospitalization. During a median follow-up of 2.5 years, the risk for progression to end-stage renal disease did not differ between the two groups (0.3 vs. 0.4 events per 100 person-years, P=0.712). Moreover, early invasive treatment was associated with reduced long-term mortality (2.4 vs. 3.4 events per 100 person-years; P<0.001). The relative reduction in mortality risk was consistent across all strata of baseline renal function.


Although early invasive treatment of acute coronary syndromes increased the risk for acute renal injury compared with conservative management, it did not affect risk for dialysis or progression to end-stage renal disease. The improvements in long-term survival at all levels of baseline renal function suggest that invasive therapy should not be withheld for fear of renal complications.

Source: NEJM

Peripheral Artery Disease Increased Dramatically Over the Past Decade Worldwide.

Lower-limb peripheral artery disease (PAD) has become a worldwide problem, and its prevalence over the past decade increased twice as fast in lower- and middle-income countries (by 29%) as it did in high-income countries (by 13%), according to Lancet estimates.

Researchers examined data from community-based studies in which PAD was defined by an ankle-brachial index of 0.90 or lower. The 34 studies encompassed over 100,000 participants.

In high-income countries, PAD prevalence did not differ between men and women, but in other countries it was higher among women. Prevalence rose with age worldwide, reaching 10% by age 70 and 17% after age 80. The most important modifiable risk factor was smoking, followed by diabetes, hypertension, and hypercholesterolemia.

The authors call the dramatic increase in prevalence — to about 200 million cases — “a major public health challenge,” given PAD’s association with loss of mobility, functional decline, and cardiovascular risk.


Anemia Tied to Increased Dementia Risk.

Older adults who have anemia face increased risk for dementia, according to a prospective cohort study in Neurology.

Researchers studied some 2600 initially dementia-free older adults, 15% of whom had anemia at baseline. During 11 years’ follow-up, 18% of participants developed dementia. After adjustment for potential confounders such as age, sex, APOE genotype, comorbid conditions, and literacy, participants with anemia had a significant, 49% increase in risk for dementia relative to those without anemia.

The researchers say their findings are consistent with those from previous studies, and they suggest several possible mechanisms underlying the association. For example, the brain hypoxia that occurs with anemia might contribute to dementia risk, or anemia could be a marker of overall poor health. They call for additional research to determine whether hemoglobin levels should be the focus of prevention strategies.

Source: Neurology

Fluoridated Water Is Causing Thyroid Health Problems.

But aside from all the sordid history, the suppression of scientific concern, and the labeling of dissenters as off-balanced “fluorophobes,” what should a sensible person do? Here are three appropriate actions for regular daily life, especially if you are bothered by feeling fat, fuzzy, frazzled, fatigued, depressed, beset by intolerance to heat or cold, annoyed by problems with skin-hair-nails, or suffering with severe constipation, low libido, infertility, or uncomfortable menopause.
First, if you are not a thyroid patient, have your thyroid status carefully checked. Insist on more testing than the simple AMA panel of TSH and Free T4. Add a Free T3 and the Thyroid Antibody Panel. You may be one of the millions of people whose fluoride exposure over the years has finally made you low thyroid.

Second, if you are already a thyroid sufferer and treatment is not going as well as you would like, consider an enhanced fluoride avoidance program. Stop drinking and cooking with tap water if it is fluoridated. Well-chosen bottled water is preferable. Start buying non-fluoridated tooth paste. It’s available at the health food store if you really look closely. Decline the fluoride dental treatments and make sure it is not in your mouth wash. The various other food sources are probably not a significant factor.

Commentary on 2006 Research Findings

Third, start speaking out against the unhealthy practice of fluoridation. Don’t expect that the Public Health Service will ever willingly admit to the most colossal error ever in the history of government science. The change will instead occur as more and more local communities decide against fluoridating their city water. They will thereby join those whole countries that have rejected or banned the practice, such as Japan, India, Finland, Denmark, Sweden, and Holland. Be guided by the credo of health professionals, “Above all, do no harm.” If fluoridated water is now highly suspected of harm, then let’s put a moratorium on proceeding further with it.