Thank you very much for the information.  I really appreciate it.     I know you
must be a very busy doctor.
I also have a web site on atrial fibrillation cures on Yahoo.  I was cured 8+
year ago by the maze procedure.
http://health.groups.yahoo.com/group/A-fibcures/
Thank you
Jack
   ----- Original Message -----
   From: dr_allen_wang
   To: heart119@yahoogroups.com
   Sent: Saturday, April 29, 2006 11:02 PM
   Subject: [Heart119] Re: Amiodarone Side Effects


   The following are the side effects of amiodarone, including rare anemia
   (in postmarketing report):

   Adverse reactions have been very common in virtually all series of
   patients treated with Cordarone for ventricular arrhythmias with
   relatively large doses of drug (400 mg/day and above), occurring in
   about three-fourths of all patients and causing discontinuation in 7 to
   18%. The most serious reactions are pulmonary toxicity, exacerbation of
   arrhythmia, and rare serious liver injury, but other adverse effects
   constitute important problems. They are often reversible with dose
   reduction or cessation of Cordarone treatment. Most of the adverse
   effects appear to become more frequent with continued treatment beyond
   six months, although rates appear to remain relatively constant beyond
   one year. The time and dose relationships of adverse effects are under
   continued study.

   Neurologic problems are extremely common, occurring in 20 to 40% of
   patients and including malaise and fatigue, tremor and involuntary
   movements, poor coordination and gait, and peripheral neuropathy; they
   are rarely a reason to stop therapy and may respond to dose reductions
   or discontinuation.

   Gastrointestinal complaints, most commonly nausea, vomiting,
   constipation, and anorexia, occur in about 25% of patients but rarely
   require discontinuation of drug. These commonly occur during high-dose
   administration (i.e., loading dose) and usually respond to dose
   reduction or divided doses.

   Ophthalmic abnormalities including optic neuropathy and/or optic
   neuritis, in some cases progressing to permanent blindness,
   papilledema, corneal degeneration, photosensitivity, eye discomfort,
   scotoma, lens opacities, and macular degeneration have been reported.
   (See "WARNINGS.")

   Asymptomatic corneal microdeposits are present in virtually all adult
   patients who have been on drug for more than 6 months. Some patients
   develop eye symptoms of halos, photophobia, and dry eyes. Vision is
   rarely affected and drug discontinuation is rarely needed.

   Dermatological adverse reactions occur in about 15% of patients, with
   photosensitivity being most common (about 10%). Sunscreen and
   protection from sun exposure may be helpful, and drug discontinuation
   is not usually necessary. Prolonged exposure to Cordarone occasionally
   results in a blue-gray pigmentation. This is slowly and occasionally
   incompletely reversible on discontinuation of drug but is of cosmetic
   importance only.

   Cardiovascular adverse reactions, other than exacerbation of the
   arrhythmias, include the uncommon occurrence of congestive heart
   failure (3%) and bradycardia. Bradycardia usually responds to dosage
   reduction but may require a pacemaker for control. CHF rarely requires
   drug discontinuation. Cardiac conduction abnormalities occur
   infrequently and are reversible on discontinuation of drug.

   The following side-effect rates are based on a retrospective study of
   241 patients treated for 2 to 1,515 days (mean 441.3 days).

   The following side effects were each reported in 10 to 33% of patients:

   Gastrointestinal: Nausea and vomiting.

   The following side effects were each reported in 4 to 9% of patients:

   Dermatologic: Solar dermatitis/photosensitivity.

   Neurologic: Malaise and fatigue, tremor/abnormal involuntary movements,
   lack of coordination, abnormal gait/ataxia, dizziness, paresthesias.

   Gastrointestinal: Constipation, anorexia. Ophthalmologic: Visual
   disturbances. Hepatic: Abnormal liver-function tests.

   Respiratory: Pulmonary inflammation or fibrosis.

   The following side effects were each reported in 1 to 3% of patients:

   Thyroid: Hypothyroidism, hyperthyroidism.

   Neurologic: Decreased libido, insomnia, headache, sleep disturbances.

   Cardiovascular: Congestive heart failure, cardiac arrhythmias, SA node
   dysfunction. Gastrointestinal: Abdominal pain.

   Hepatic: Nonspecific hepatic disorders.

   Other: Flushing, abnormal taste and smell, edema, abnormal salivation,
   coagulation abnormalities.

   The following side effects were each reported in less than 1% of
   patients:

   Blue skin discoloration, rash, spontaneous ecchymosis, alopecia,
   hypotension, and cardiac conduction abnormalities.

   In surveys of almost 5,000 patients treated in open U.S. studies and in
   published reports of treatment with Cordarone, the adverse reactions
   most frequently requiring discontinuation of Cordarone included
   pulmonary infiltrates or fibrosis, paroxysmal ventricular tachycardia,
   congestive heart failure, and elevation of liver enzymes. Other
   symptoms causing discontinuations less often included visual
   disturbances, solar dermatitis, blue skin discoloration,
   hyperthyroidism, and hypothyroidism.

   Postmarketing Reports

   In postmarketing surveillance, sinus arrest, hepatitis, cholestatic
   hepatitis, cirrhosis, epididymitis, impotence, vasculitis, pseudotumor
   cerebri, syndrome of inappropriate antidiuretic hormone secretion
   (SIADH), acute renal failure, renal impairment, renal insufficiency,
   thrombocytopenia, angioedema, bronchiolitis obliterans organizing
   pneumonia (possibly fatal), bronchospasm, possibly fatal respiratory
   disorders (including distress, failure, arrest, and ARDS), fever,
   dyspnea, cough, hemoptysis, wheezing, hypoxia, pulmonary infiltrates,
   pleuritis, pancreatitis, toxic epidermal necrolysis, myopathy, muscle
   weakness, rhabdomyolysis, hemolytic anemia, aplastic anemia,
   pancytopenia, neutropenia, agranulocytosis, erythema multiforme,
   Stevens-Johnson syndrome, exfoliative dermatitis, and pruritus, also
   have been reported in patients receiving Cordarone.




   --- In heart119@yahoogroups.com, "jackdrum" <jackdrum1@...> wrote:
   >
   > Dr. Wang, have you ever came across information about anyone on
   > Amiodarone having the side effect of not making enough Red Blood
   > Cells.
   > He has been checked by a good oncologist and no sign of cancer.
   > A friend of mine has to get usually 2 units of blood about every 2
   > weeks.   This has been ongoing for about 6 months.  No one has been
   > able to find the reason why.     He has been on Amiodarone for atrial
   > fibrillation, and
   > I was wondering if this could be a side effect of the Amiodarone.   I
   > have tried to find this in the Amiodarone side effects, but haven't
   > found it.
   > Thank you very much.
   > Jack Drum
   >






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[Non-text portions of this message have been removed]

Immediate treatment of patients who have suffered an aneurysmal
subarachnoid hemorrhage (SAH) with pravastatin for 14 days reduces
morbidity and mortality, according to results from a small
randomized trial presented here at the 2006 annual meeting of the
American Association of Neurological Surgeons.

In the United Kingdom, SAH accounts for 3% of all strokes but it
accounts for 25% of productive life lost to such events because SAH
strokes occur in younger patients, with a mean age of 55 years vs 74
years for ischemic strokes. In addition, 50% of SAH patients die
from the event and one third of those who survive remain dependent
on caregivers in the long term.

Ming-Yuan Tseng, MD, MSc, from the Department of Neurosurgery at
Addenbrooke's Hospital at the University of Cambridge, United
Kingdom, and colleagues hypothesized that acute treatment with
statins may limit morbidity and mortality in SAH patients by
mitigating vasospasms and improving cerebral autoregulation.

In the current study, 80 patients were randomized to receive either
40 mg of pravastatin per day or placebo for 14 days. All therapy was
initiated within 72 hours of the SAH. Patients also received 60 mg
nimodipine every 4 hours and fluid intake of at least 3 liters per
day for up to 21 days. Severe vasospasms were treated with "3H-
therapy" (hypertension-hypervolemia-hemodilution) as standard care.

Each day, patients were assessed by transcranial doppler (TCD) for
vasospasm, underwent the transient hyperaemic response test (THRT)
to assess autoregulation, and were examined neurologically to
determine the amount of delayed ischemic deficits.

"Acute treatment with statins following SAH ameliorates vasospasm-
related complications, including delayed ischemic deficits,
mortality, and disability," Dr. Tseng said.

Twenty-five patients (62.5%) in the placebo group had detectable
vasospasms during the 2 weeks of therapy compared with 17 patients
(42.5%) in the statin group (P = .006). Severe vasospasm occurred in
12 patients (30.0%) in the placebo group and 7 patients (17.5%) in
the active-drug group (P = .044). Patients in the placebo group also
had a higher incidence of vasospasm-related delayed ischemic
deficits than those in the statin group (30.0% vs 5.0%; P < .001).

"When the trial finished, the patients who had been on statins
started to have vasospasms," Dr. Tseng pointed out. Delayed ischemic
deficits also increased in patients who were taken off the active
drug.

Autoregulation impairment was reduced on both sides of the brain in
patients receiving statin therapy compared with those receiving
placebo (3.0 กำ 3.4 days vs 5.3 กำ 4.5; P = .011 on the ipsilateral
side; 1.6 กำ 2.2 vs 3.7 กำ 4.3; P = .008 on the contralateral side.)

Finally, mortality was also reduced from 20% to 5%. Intensive care
unit stays were reduced from 56.5 days in the placebo group to 20.9
days in the statin group (P = .04)

In a linear regression analysis of health quality for the 60
patients who survived 6 months, the researchers found that the only
variable that predicted improved SF-36 scores was the use of
pravastatin (P < .001; information was not provided about how many
patients survived in each group).

Liver function changes were not detected. Looking for the
physiological underpinnings of these results, Dr. Tseng showed that
serum C-reactive protein levels, an indicator of inflammatory
response, was significantly lower in statin-treated patients than in
control patients (22.49 U/L vs 55.83 U/L; P = .042). The increase in
fibrinogen was 55% between day 0 and day 3 in the placebo group and
35.8% in the statin group, which was not statistically different (P
= .09).

"Looking through the results, the things that really stick out and
are really robust are the decreased incidence of delayed ischemic
neurological deficits and the decreased mortality," said E. Sander
Connolly, Jr, MD, assistant professor of neurosurgery at Columbia
University in New York City. "These things are the important things.
The issues of spasm are softer."

The reason this study looks so promising is because the drug appears
to improve cerebral blood flow via numerous mechanisms, Dr. Connolly
said. That said, he cautioned that the trial size is very small and
only a fraction of the patients completed therapy (38% in the
placebo group and 58% in the statin group). Thus, although other
groups also have seen promising results with other statins in the
treatment of SAH, he tempered his enthusiasm for the data. "This is
an exciting start, but we really need to get more data before we
look for an effect size in a larger trial," he concluded.

AANS 2006 Annual Meeting: Abstracts 702. Presented April 25, 2006

Cerebral emboli are significantly more common in patients with
Alzheimer's disease and vascular dementia than in their healthy
counterparts, according to a report in the April 27th online first
issue of the British Medical Journal.

Given these findings, cerebral emboli "may represent a potentially
preventable or treatable cause of dementia," senior author Dr.
Charles McCollum, from the University of Manchester in the UK, and
colleagues comment.

In the new study, Dr. McCollum's team used transcranial Doppler to
assess the occurrence of spontaneous cerebral emboli in 85 patients
with Alzheimer's disease, 85 patients with vascular dementia, and in
150 matched controls.

Cerebral emboli rates for patients with Alzheimer's disease and
vascular dementia were 40% and 37%, respectively. By contrast, among
controls, the rate was around 14%.

However, the source of the extra emboli in demented patients was
unclear. The emboli did not seem to arise from the carotid vessels,
since the frequency of carotid disease was similar among patients
and controls. Likewise, paradoxical embolization did not seem to be
a major contributor since the rates of venous-to-arterial shunt,
indicating a patent foramen ovale, were not significantly different
between the groups.

"This study is the first to show an association between spontaneous
cerebral emboli and dementia," the investigators state. "The similar
frequency of emboli in both types of dementia suggests a common
cause and shared pathophysiology."

BMJ 2006

Men with Klinefelter syndrome are very likely to experience a
variety of other complaints, Danish researchers report "Klinefelter
syndrome patients suffer from a significantly increased morbidity,
with more frequent hospital admissions from almost any disease,"
lead researcher Dr. Anders Bojesen told Reuters Health.

Klinefelter syndrome is the most prevalent sex chromosome disorder,
affecting about 1 in 660 men, the researchers note in the April
issue of the Journal of Endocrinology and Metabolism.

To further investigate the morbidity associated with this disorder,
Dr. Bojesen of Aarhus University Hospital and colleagues followed
832 subjects and 4033 controls for about 100,000 person years.

Klinefelter syndrome patients had a significantly increased risk of
hospitalization (hazard ratio, 1.69). The highest hazard ratio
(10.7) for hospitalization was for congenital malformations.
Hospitalization rates were also particularly high for psychiatric
disorders (hazard ratio, 3.7) and for endocrine and metabolic
disorders (hazard ratio, 3.2).

The researchers estimate that only one in four men with Klinefelter
syndrome are diagnosed. In the current study, hospitalization rates
were elevated in the patients even before a diagnosis was made.

These and other studies said Dr. Bojesen, "highlight the need for
better care of the Klinefelter patient; early diagnosis, sufficient
testosterone treatment and close follow-up may prevent much of the
extra morbidity."

"There is also a definite need for randomized placebo-controlled
trials on the effect of testosterone treatment on many aspects of
Klinefelter syndrome," he added.

These important studies, Australian researcher Dr. David J.
Handelsman, co-author of an accompanying editorial, told Reuters
Health "outline clearly diverse harmful health consequences of
lifelong androgen deficiency."

Dr. Handelsman of the ANZAC Research Institute, Sydney also noted
that the findings underscore "how frequently this easily treatable
hormonal deficiency is overlooked because men's standard medical
care does not include reproductive health examination, long a
routine for women."

J Clin Endocrinol Metab 2006;91:1220-1222,1254-1260

The benefits of selective embolization of pulmonary arteriovenous
malformations (PAVM) are usually maintained over many years, as
demonstrated by helical computed tomography follow-up, investigators
in France report.

Large PAVMs often cause right-to-left shunts, leaving the patient
with symptoms such as dyspnea, fatigue and cyanosis, and increased
risk of stroke or cerebral aneurysm, Dr. Martine Remy-Jardin and
associates note. While transcatheter embolotherapy is the first-line
treatment of PAVMs, the current study, reported in the May issue of
Radiology, has the longest follow-up of this treatment to date.

Dr. Remy-Jardin's team, at the University Center of Lille,
retrospectively evaluated outcomes for 38 patients with a total of
64 PAVMs with feeding arteries of 3 mm or greater. Pulmonary
arterial circulation was occluded by depositing steel coils (Cook,
Bloomington, Indiana) in the feeding arteries.

The authors report that all treated PAVMs were initially
successfully occluded (84% in one session and 16% in two sessions),
as demonstrated by the cessation of aneurysmal perfusion. A mean of
3.92 coils were required for the simple PAVMs and 7.09 for the
complex malformations.

After a mean follow-up of 9.74 years, the success rate as determined
by helical CT was 75% (complete occlusion in 47% of cases; partial
success, with diminution of the aneurysmal sac and feeding arteries
less than 3 mm in diameter, 28%).

Causes of failure included recanalization of occluded feeding
arteries in 10 cases, previously unrecognized additional feeding
arteries of complex PAVMs in three cases, and development of
systemic perfusion of the aneurysmal sac in one case. Repeat
occlusion was performed for delayed recanalization in 12 cases.

The only factors linked to embolotherapy failure were pulmonary
hypertension and gastrointestinal and/or hepatic shunts. Other
potential risk factors -- anatomic characteristics of PAVMs; the
mean number of coils required to obstruct the malformation,
regardless of the size of the feeding arteries; age, gender or
hereditary hemorrhagic telangiectasia -- did not appear to affect
outcomes.

Radiology 2006;239:576-585

Tumor necrosis factor alpha (TNF) blockade may be a novel strategy
to reduce inflammation and improve cardiovascular risk in patients
with the metabolic syndrome, report Boston-based clinicians in the
April 24th issue of the Archives of Internal Medicine.

"Metabolic syndrome is common -- seen in up to 25 million
Americans," Dr. Steven K. Grinspoon from Massachusetts General
Hospital noted in comments to Reuters Health. "Excess visceral
abdominal fat seen in the metabolic syndrome is known to produce
cytokines, such as TNF, that result in increased inflammation and
cardiovascular risk."

Dr. Grinspoon and colleagues used the arthritis medication,
etanercept, which blocks TNF action, to interrupt this inflammatory
cascade resulting from excess visceral fat. They randomized 56
patients with the metabolic syndrome to etanercept, 50 mg
subcutaneously once a week for 4 weeks, or matching placebo.

C-reactive protein levels -- the primary endpoint -- decreased
significantly over 4 weeks in the etanercept arm compared with the
placebo arm. Other markers of inflammation, including fibrinogen and
interleukin-6, were also reduced.

Adiponectin levels rose significantly in the etanercept group
compared with the placebo group. There were no changes in body
composition parameters or insulin sensitivity, but HDL cholesterol
levels tended to fall in the etanercept arm.

The investigators also report that etanercept proved safe in this
group of patients with the metabolic syndrome "strictly screened"
for contraindications to the drug.

This study, Dr. Grinspoon and colleagues conclude, shows that
etanercept "reduces CRP levels and tends to improve other
inflammatory cardiovascular risk indexes in patients with the
metabolic syndrome. Further longer-term studies are needed to
determine the effects of TNF-alpha inhibition on cardiovascular
disease in this patient population, they add.

Arch Intern Med 2006;166:902-908

Asymptomatic patients at high risk for cardiovascular disease (CVD)
who are able to see the calcium deposited in their coronary arteries
(CAC) are more apt to take lipid-lowering drugs and to alter their
behavioral risk factors, new study findings suggest.

Even though the benefits of lipid-lowering agents are well known,
they are not used as often as they should be among at-risk patients,
Dr. Matthew J. Budoff and colleagues note in their report, published
in the April issue of Atherosclerosis.

The research team performed electron beam tomography (EBT), which
shows CAC as bright white spots in their coronary arteries. Patients
with baseline CVD, those with interim cardiac events, and those who
weren't prescribed a statin were excluded.

The remaining 505 subjects completed questionnaires regarding risk
factors at baseline and 3 years later, and were stratified according
to CAC score quartiles.

The results showed that "seeing is believing." Among patients in the
first quartile, 52% adhered to statin therapy, which increased to
91% in the fourth quartiles, (p = 0.0001). Dietary modification
increased from 41% among those with the lowest CAC score to 64%
among those with the highest (p = 0.001).

Similar patterns were observed among subjects who smoked or who had
hypertension, diabetes, or a family history of coronary heart
disease. After adjusting for these confounders, subjects in the
highest quartile were 10 times more likely to persist with lipid-
lowering therapy compared with those in the first quartile.

Dr. Budoff, from the Harbor-UCLA Medical Center in Torrance,
California, and his team "believe that the improved adherence in our
study reflected a change in the patients' (and their physicians')
perceived threat of their atherosclerotic disease after their EBT
test."

They also note that multi-detector CT, which also displays CAC,
would be a reasonable substitute for EBT.

Atherosclerosis 2006;185:394-399

The following are the side effects of amiodarone, including rare anemia
(in postmarketing report):

Adverse reactions have been very common in virtually all series of
patients treated with Cordarone for ventricular arrhythmias with
relatively large doses of drug (400 mg/day and above), occurring in
about three-fourths of all patients and causing discontinuation in 7 to
18%. The most serious reactions are pulmonary toxicity, exacerbation of
arrhythmia, and rare serious liver injury, but other adverse effects
constitute important problems. They are often reversible with dose
reduction or cessation of Cordarone treatment. Most of the adverse
effects appear to become more frequent with continued treatment beyond
six months, although rates appear to remain relatively constant beyond
one year. The time and dose relationships of adverse effects are under
continued study.

Neurologic problems are extremely common, occurring in 20 to 40% of
patients and including malaise and fatigue, tremor and involuntary
movements, poor coordination and gait, and peripheral neuropathy; they
are rarely a reason to stop therapy and may respond to dose reductions
or discontinuation.

Gastrointestinal complaints, most commonly nausea, vomiting,
constipation, and anorexia, occur in about 25% of patients but rarely
require discontinuation of drug. These commonly occur during high-dose
administration (i.e., loading dose) and usually respond to dose
reduction or divided doses.

Ophthalmic abnormalities including optic neuropathy and/or optic
neuritis, in some cases progressing to permanent blindness,
papilledema, corneal degeneration, photosensitivity, eye discomfort,
scotoma, lens opacities, and macular degeneration have been reported.
(See "WARNINGS.")

Asymptomatic corneal microdeposits are present in virtually all adult
patients who have been on drug for more than 6 months. Some patients
develop eye symptoms of halos, photophobia, and dry eyes. Vision is
rarely affected and drug discontinuation is rarely needed.

Dermatological adverse reactions occur in about 15% of patients, with
photosensitivity being most common (about 10%). Sunscreen and
protection from sun exposure may be helpful, and drug discontinuation
is not usually necessary. Prolonged exposure to Cordarone occasionally
results in a blue-gray pigmentation. This is slowly and occasionally
incompletely reversible on discontinuation of drug but is of cosmetic
importance only.

Cardiovascular adverse reactions, other than exacerbation of the
arrhythmias, include the uncommon occurrence of congestive heart
failure (3%) and bradycardia. Bradycardia usually responds to dosage
reduction but may require a pacemaker for control. CHF rarely requires
drug discontinuation. Cardiac conduction abnormalities occur
infrequently and are reversible on discontinuation of drug.

The following side-effect rates are based on a retrospective study of
241 patients treated for 2 to 1,515 days (mean 441.3 days).

The following side effects were each reported in 10 to 33% of patients:

Gastrointestinal: Nausea and vomiting.

The following side effects were each reported in 4 to 9% of patients:

Dermatologic: Solar dermatitis/photosensitivity.

Neurologic: Malaise and fatigue, tremor/abnormal involuntary movements,
lack of coordination, abnormal gait/ataxia, dizziness, paresthesias.

Gastrointestinal: Constipation, anorexia. Ophthalmologic: Visual
disturbances. Hepatic: Abnormal liver-function tests.

Respiratory: Pulmonary inflammation or fibrosis.

The following side effects were each reported in 1 to 3% of patients:

Thyroid: Hypothyroidism, hyperthyroidism.

Neurologic: Decreased libido, insomnia, headache, sleep disturbances.

Cardiovascular: Congestive heart failure, cardiac arrhythmias, SA node
dysfunction. Gastrointestinal: Abdominal pain.

Hepatic: Nonspecific hepatic disorders.

Other: Flushing, abnormal taste and smell, edema, abnormal salivation,
coagulation abnormalities.

The following side effects were each reported in less than 1% of
patients:

Blue skin discoloration, rash, spontaneous ecchymosis, alopecia,
hypotension, and cardiac conduction abnormalities.

In surveys of almost 5,000 patients treated in open U.S. studies and in
published reports of treatment with Cordarone, the adverse reactions
most frequently requiring discontinuation of Cordarone included
pulmonary infiltrates or fibrosis, paroxysmal ventricular tachycardia,
congestive heart failure, and elevation of liver enzymes. Other
symptoms causing discontinuations less often included visual
disturbances, solar dermatitis, blue skin discoloration,
hyperthyroidism, and hypothyroidism.

Postmarketing Reports

In postmarketing surveillance, sinus arrest, hepatitis, cholestatic
hepatitis, cirrhosis, epididymitis, impotence, vasculitis, pseudotumor
cerebri, syndrome of inappropriate antidiuretic hormone secretion
(SIADH), acute renal failure, renal impairment, renal insufficiency,
thrombocytopenia, angioedema, bronchiolitis obliterans organizing
pneumonia (possibly fatal), bronchospasm, possibly fatal respiratory
disorders (including distress, failure, arrest, and ARDS), fever,
dyspnea, cough, hemoptysis, wheezing, hypoxia, pulmonary infiltrates,
pleuritis, pancreatitis, toxic epidermal necrolysis, myopathy, muscle
weakness, rhabdomyolysis, hemolytic anemia, aplastic anemia,
pancytopenia, neutropenia, agranulocytosis, erythema multiforme,
Stevens-Johnson syndrome, exfoliative dermatitis, and pruritus, also
have been reported in patients receiving Cordarone.




--- In heart119@yahoogroups.com, "jackdrum" <jackdrum1@...> wrote:
>
> Dr. Wang, have you ever came across information about anyone on
> Amiodarone having the side effect of not making enough Red Blood
> Cells.
> He has been checked by a good oncologist and no sign of cancer.
> A friend of mine has to get usually 2 units of blood about every 2
> weeks.   This has been ongoing for about 6 months.  No one has been
> able to find the reason why.     He has been on Amiodarone for atrial
> fibrillation, and
> I was wondering if this could be a side effect of the Amiodarone.   I
> have tried to find this in the Amiodarone side effects, but haven't
> found it.
> Thank you very much.
> Jack Drum
>

Dr. Wang, have you ever came across information about anyone on
Amiodarone having the side effect of not making enough Red Blood
Cells.
He has been checked by a good oncologist and no sign of cancer.
A friend of mine has to get usually 2 units of blood about every 2
weeks.   This has been ongoing for about 6 months.  No one has been
able to find the reason why.     He has been on Amiodarone for atrial
fibrillation, and
I was wondering if this could be a side effect of the Amiodarone.   I
have tried to find this in the Amiodarone side effects, but haven't
found it.
Thank you very much.
Jack Drum

The final results of a phase I study of autologous bone marrow cell
transplantation in patients with advanced heart disease show that
the technique is safe and feasible. In addition, the procedure
appears to improve symptoms and the benefits are sustained at the 1-
year follow-up point.

Patients in the study were classified as "no option." They were on
maximal medical therapy, with refractory angina and myocardial
ischemia, and were not candidates for surgery.

Dr. Shumuel Fuchs of Columbia University Medical Center in New York
and colleagues injected 27 patients with nucleated bone marrow cells
containing 2.2% CD34+ cells directed into infarcted heart muscle.
The procedure was successful and caused no adverse events in any of
the patients.

At 3 months follow-up, Canadian Cardiovascular Society angina score
improved from 3.2 at baseline to 2.0 at follow-up. Treadmill
exercise duration improved from 418 seconds to 489 seconds. Stress-
induced ischemia scores also improved in the injected territories.

Improvements were sustained at 1 year, the Columbia team reports in
the March 15th issue of the American Journal of Cardiology. Five
patients were able to undergo revascularization.

Bone marrow cell transplantation needs to be further explored, as
the number of nucleated cells (CD45+), progenitor cells (CD34+), and
the magnitude of secreted vascular endothelial growth factor and
macrophage chemoattractant protein-1 did not predict clinical
response, the investigators report..

Dr. Fuchs told Reuters Health that "phase II studies will involve
injection of subpopulation of cells rather than a whole bone
marrow." And while clinical benefits with this approach have been
sustained, "we do not yet know whether repeated injection will be a
better approach. As of today, this approach was not tested."

"The gathering of data is a continuous process and it takes time,"
Dr. Fuchs commented. "We understand today that there are still
multiple open questions. The number of required cells may differ,
depending on the cell being used." A number of potential safety
concerns still remain.

"With BM cells, there is the potential for mild aggravation of
atherosclerosis....We need a large study in order to clarify this
point. All of these patients([in the study) are those with naturally
highly progressive CAD "

Am J Cardiol 2006;97:823-829

Cardioversion appears to be more successful in maintaining sinus
rhythm in patients with new-onset atrial flutter than in patients
with recurrent atrial flutter or atrial fibrillation, according to a
new report.

Recent trials of rate control versus rhythm control for atrial
fibrillation or flutter have included few patients with new-onset
arrhythmia, the authors explain in the April issue of the European
Heart Journal.

Therefore, Dr. Ahmad A. Elesber and colleagues from Mayo Clinic,
Rochester, Minnesota compared the arrhythmia relapse rate and
mortality after cardioversion in a cohort of 351 patients who had
new-onset atrial fibrillation or atrial flutter, or recurrent atrial
fibrillation or atrial flutter.]

One year after cardioversion, 63% of the patients in the new-onset
atrial flutter group maintained normal sinus rhythm, the authors
report, compared with only 30% of patients in the new-onset atrial
fibrillation group, 33% of patients in the recurrent atrial flutter
group, and 35% of patients in the recurrent atrial fibrillation
group.

The four groups did not differ in the need for a pacemaker for
symptomatic atrial dysrhythmia or atrioventricular node ablation
after drug treatment failed.

After adjusting for other prognostic variables, relapse of atrial
fibrillation or atrial flutter after cardioversion was associated
with a threefold increase in the risk of death, the researchers
note. The type of atrial arrhythmia at baseline was not a
significant predictor of death.

"Prospective studies are needed to assess whether the strategy of
using anti-arrhythmic medications after cardioversion in symptomatic
elderly patients with new-onset atrial fibrillation is effective,"
the investigators write. "The fact that patients with new-onset
atrial fibrillation had a similar rate of relapse as patients with
recurrent atrial fibrillation underlies the importance of using
anticoagulation even in patients with new onset atrial fibrillation."

"Anticoagulation in this group of patients should be discontinued
only after strong consideration of the risks and benefits," the
authors conclude.

"Careful attention is warranted when atrial arrhythmias recur in
patients after successful cardioversion because they have a higher
mortality rate than in patients who maintain sinus rhythm," the
investigators add.

Eur Heart J 2006;27:854-860

For some patients with end-stage congestive heart failure (CHF) due
to idiopathic dilated cardiomyopathy, oral amiodarone and weekly
infusions of dobutamine may prolong survival, improve function, and
cause reverse left ventricular remodeling, Greek investigators
report.

Continuous IV inotropic agents such as dobutamine may improve
symptoms in these critically ill patients, but this treatment may
also be lethal, Dr. John N. Nanas, of the University of Athens
School of Medicine, and his colleagues note. In their earlier
studies, they found that most patients who were not treated with
amiodarone and dobutamine died within 3 months.

They theorized that intermittent dobutamine infusions added to
amiodarone therapy would positively affect hemodynamics and left
ventricular geometry.

According to their report in the April issue of the International
Journal of Cardiology, 16 treatment-refractory patients with
symptoms of CHF were prospectively followed for at least 1 year.
Their left ventricular ejection fraction (LVEF) averaged 22% at
baseline.

The patients received the antiarrhythmic agent amiodarone 400 mg/day
and weekly IV dobutamine infusions of 10 g/kg/min for 8 hours. Seven
patients died within 6 months of the treatment change.

The LVEF of the remaining nine patients increased by 24%. Left
ventricular size and ventricular filling pressures decreased
gradually, and the right atrial pressure normalized over 12 months
of follow-up.

Among the survivors, Dr. Nanas' team observed that the New York
Heart Association functional class improved from 4.0 at baseline to
2.1 at 12 months and all of the patients were able to exercise at 6
months.

Five patients were weaned from the dobutamine infusions between 20
and 118 weeks of treatment, and four remained clinically stable for
up to 183 weeks after dobutamine discontinuation.

"Two of these four patients have returned to unlimited professional
activities," they note.

Dr. Nanas and his team conclude that "although the degree of
clinical improvement in our patients was less than can be expected
from long-term left ventricular assistive device implantation, the
time course and the putative fundamental mechanism were similar."

Int J Cardiol 2006;118;237-243

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Adding a low dose of spironolactone to a standard angiotensin-
converting enzyme (ACE) inhibitor reduces albuminuria in patients
with type 2 diabetes, according to preliminary findings of a pilot
study. The effect was seen in patients with both microalbuminuria
and macroalbuminuria, and the addition caused no adverse effects,
including no significant hyperkalemia.

"The purpose of this study was to look at patients with type 2
diabetes and albuminuria, which is certainly one of the most
prevalent problems we encounter in type 2 diabetes," lead author
Michael Benjamin Davidson, DO, from the Cleveland Clinic Foundation
in Ohio, told Medscape. Dr. Davidson presented preliminary data on
18 patients here at the 15th annual meeting of the American
Association of Clinical Endocrinologists.

"Patients with albuminuria and type 2 diabetes are at increased risk
of developing end-stage renal disease (ESRD), and ESRD from diabetes
is the most frequent cause of dialysis in this country. We know
those patients are also at great risk of developing coronary disease
and death from all-cause mortality," he said.

"Despite the widespread use of ACE inhibitors and angiotensin-
receptor blockers (ARBs), many continue to have proteinuria. In a
number of studies it has been shown that despite ACE inhibitors and
ARBs, you can measure elevated levels of aldosterone, and one would
presume that, based on the mechanism, that you would suppress
aldosterone with those agents."

Preliminary data from other studies has demonstrated a benefit to
giving spironolactone in addition to ACE inhibition, Dr. Davidson
noted. "We attempted to design a trial that looked at just diabetic
nephropathy, and within that, both microalbuminuria and
macroalbuminurea."

This open-label pilot intervention trial has an enrollment goal of
40 subjects, with 18 studied to date. The trial requires that
subjects visit the clinic 4 times during 12 weeks, with laboratory
and clinical assessment at each visit. By design, 20 subjects will
have macroalbuminuria (random albumin/creatinine ratio [ACR], 300
mg/g), and 20 will have microalbuminuria (ACR, 100-300 mg/g).

Four weeks after consent, the patient starts spironolactone therapy,
and 4 weeks later, stops it. Four weeks after stopping, the patient
returns for a follow-up visit. At each visit the patient's blood
pressure, metabolic panel, 24-hour urine albumin, and 24-hour urine
creatinine levels are recorded.

Study inclusion criteria are: type 2 diabetes; use of any ACE
inhibitor, at any dose, for more than 30 days; and a urine
albumin/creatinine ratio of 100 mg/g. Exclusion criteria are:
creatinine levels higher than 2.0 mg/dL; potassium levels higher
than 5.3 mmol/L; uncontrolled hypertension, overt heart failure, or
active febrile illness; use of any ARB, spironolactone, or other
potassium-sparing diuretic; and nondiabetic renal disease.

Paired t tests and Wilcoxon signed rank tests were applied to
compare different visits as appropriate.

Baseline patient characteristics to date (n = 18) are: age, 58.5 กำ
9.1 years; African-American race, 6 patients (30%); male sex, 15
patients (75%).

The preliminary group of 18 patients includes 11 with
macroalbuminuria and 7 with microalbuminuria. The preliminary
conclusion is that adding a low dose of spironolactone once daily
for 4 weeks results in a significant decrease in 24-hour creatinine
and urine albumin excretion (UAE) levels in patients with type 2
diabetes who are already receiving ACE inhibitors.

"We saw a statistically significant drop in proteinuria after
initiating spironolactone," Dr. Davidson told Medscape. "If you look
at the percentage drop in the overall 18 patients, [there was a] 26%
reduction in the albuminuria after the addition of spironolactone.
In the micro group it was 34%, in the macro group, 21%. And those
were all statistically significant."

Dr. Davidson added, "There was a concomitant drop in systolic blood
pressure when we added spironolactone. However, when we looked at
the correlation between albumin excretion, decline in albumin
excretion, and decline in systolic blood pressure, they did not
correlate. The correlation coefficient was 0.08. So it seems that
the drop in systolic blood pressure was not driving the drop in
albumin excretion, which I think is a very important finding," he
told Medscape.

"No patients withdrew from the study because of adverse
effects. "There was no significant hyperkalemia, and I think most
clinicians when they hear about adding spironolactone to an ACE
inhibitor, you think about hyperkalemia as a significant adverse
effect, but there was no significant hyperkalemia," Dr. Davidson
said.

Asked whether this study should change clinical practice, Dr.
Davidson was cautious.

"I think at this point you can't make the recommendation that every
patient with proteinuria be put on spironolactone. Certainly you
have to look at patient's renal function. With worsening renal
function, you have the potential for developing hyperkalemia when
you add those agents such as ACE inhibitors and spironolactone. I
think what this does is open the door for larger randomized,
prospective trials," he said.

Farhad Zangeneh, MD, assistant clinical professor of medicine at
George Washington University School of Medicine in Washington, DC,
was even more cautious.

"The safety and efficacy of aldosterone inhibitors in the treatment
of proteinuric renal disease remain to be defined," Dr. Zangeneh
told Medscape.

"Because aldosterone escape occurs even in patients taking both an
ACE inhibitor and an ARB, there is rationale for using all 3
inhibitors. There is experimental data that suggests that
aldosterone may also be important in progressive nephropathy. In
experimental hypertensive nephrosclerosis, treatment with Aldactone
(spironolactone) is effective in preventing scarring and loss of
renal function, and infusion of aldosterone with [a] concomitant ACE
inhibitor effectively negates the protection provided by [the] an
ACE inhibitor," Dr. Zangeneh said.

He observed that spironolactone has been studied extensively for the
treatment of congestive heart failure.

"The Randomized Aldactone Evaluation Study (RALES), which compared
the effect of spironolactone to placebo in addition to standard
therapy consisting of an ACE inhibitor, [a] loop diuretic, and
digoxin, was stopped early because of a 30% reduction in all-cause
mortality in the spironolactone group. A relatively low dose of 25
mg was used, and the effect was independent of the antihypertensive
effect. Spironolactone was also well tolerated, with a small but
significant rise in serum potassium. These data raise the question
of whether aldosterone alone or in combination with other agents
that inhibit the [renin-angiotensin system] would be effective for
the treatment of progressive nephropathy," Dr. Zangeneh pointed out.

"Of concern is the potential for life-threatening hyperkalemia,
particularly in patients with advanced renal insufficiency, or a
predisposition to hyperkalemia, such as type 2 diabetics with type 4
renal tubular acidosis," Dr. Zangeneh concluded.

AACE 15th Annual Meeting: Abstract 166. Presented April 27, 2006

In certain pediatric patients with congenital heart disease, levels
of B-type natriuretic protein (BNP) are closely associated with
ventricular function, German researchers report in the April issue
of the European Journal of Cardiology.

"BNP is not a useful diagnostic tool in children with cardiac
outflow stenoses, " lead researcher Dr. Andreas Koch told Reuters
Health, but it can help determine myocardial function and volume
load.

Dr. Koch and colleagues at the University of Erlangen-Nurnberg note
that BNP levels are of use in evaluating adults with congestive
heart failure.

To investigate whether BNP might also be of some diagnostic value in
pediatric patients with congenital heart disease, the researchers
studied 288 such patients and healthy controls. Their mean age was 6
years.

In those with left-to-right shunt, BNP was increased and positively
correlated with shunt volume, systolic right ventricular pressure
and mean pressure of the pulmonary artery.

In patients with left or right heart obstruction, there was no
correlation between BNP and invasive pressure gradient or extent of
ventricular hypertrophy.

Patients with functionally univentricular heart had significantly
elevated BNP levels. Unexpectedly, say the investigators, there was
no decrease following unloading by cavopulmonary connection.

In patients with tetralogy of Fallot, there was no significant
increase in BNP.

Altogether, the team points out, "there was not a simple straight
correlation between plasma BNP and pressure or volume load,
regardless of the underlying cardiac effect."

The researchers conclude that BNP levels appear likely to
reflect "the degree of impairment of the ventricles because of the
increased volume and pressure work."

Sequenced measurements of BNP, added Dr. Koch, "might be useful
especially in the follow-up of patients with known heart disease
with residual problems - to decide when we have to send them to the
cath lab, to surgery or to re-evaluate the hemodynamic data."

Eur Heart J 2006;27:861-866

For patients with heart failure, the "patient journey" score is
better with carvedilol than with metoprolol, according to a report
in the April 18th Journal of the American College of Cardiology.

"Patient journey" is calculated by adjusting days alive and out of
the hospital using a 5-point score completed by the patient, the
authors explain.

Dr. John G. F. Cleland from University of Hull, Kingston-upon-Hull,
UK and colleagues used data for 3029 participants in the Carvedilol
or Metoprolol European Trial (COMET) study to compare patient
journey results for the two treatments.

Over 4 years, 17% of days of follow-up were lost through death, 1.4%
through hospitalization, and 23% through impaired quality of life in
both treatment groups, the authors report.

Compared with metoprolol, carvedilol reduced the total number of
days lost over the 4 years from 45% to 43%.

Using the distribution of outcomes analysis, the researchers
calculate that one in every eight patients switched from metoprolol
to carvedilol would have an absolute improvement of 10% in patient
journey scores over 4 years, about the equivalent of an extra 5
months of full health.

Overall patient journey scores were similar in men and women, but
loss through death tended to be greater in men and loss of well-
being tended to be greater in women, the report indicates.
Carvedilol appeared superior to metoprolol in all groups studied.

"This analysis shows that simple, serial direct measures of patient
well-being are feasible," the authors conclude. "This study also
emphasizes that improving patient well-being is an important unmet
patient need and goal of therapy that has not been well reported in
large outcome studies, with few exceptions."

"Beyond implications for trial design, sharpening focus on the
patient journey provides vital information in the importance that
patients place on how well they live as well as how long they live,"
write Dr. Lynne Warner Stevenson and Dr. Eldrin Lewis from Brigham
and Women's Hospital, Boston, Massachusetts in a related editorial.

Clinicians should "think about extending life rather than delaying
death," Dr. Cleland told Reuters Health. "Quality as well as
quantity of life matter. Each patient is different and will weigh
the value of quality and quantity differently."

J Am Coll Cardiol 2006;47:1603-1611,1612-1614

Whites, women, older individuals, and nonsmokers are more likely
than others to experience significant lipid changes with statin
therapy, according to a new report.

"Statins have been proven to be beneficial lipid-lowering drugs
across all subgroups of at-risk persons, but their effectiveness in
lowering LDL is affected by phenotypic and genetic characteristics,"
Dr. Joel A. Simon from Veterans Affairs Medical Center in San
Francisco, told Reuters Health.

Dr. Simon and colleagues used data from 944 participants in the
Cholesterol and Pharmacogenetics Study to examine the nongenetic,
phenotypic, and demographic predictors of the lipid-lowering
response to statins.

In a multivariate analysis, race/ethnicity, age, and smoking status
were significant predictors of the LDL response to simvastatin,
according to the study findings, published in the March 15th issue
of the American Journal of Cardiology.

Compared with whites, African Americans had a 3-mg/dL smaller
decrease in LDL cholesterol and a 1-mg/dL smaller increase in HDL
cholesterol, the authors report, and older participants had a more
robust decline in LDL than did younger participants. Smokers had a 4-
mg/dL smaller decrease in LDL compared with nonsmokers. The mean
increase in HDL cholesterol was higher in women (2 mg/dL) than in
men (1 mg/dL), the results indicate.

The only factors independently associated with a change in
triglyceride levels were waist circumference and smoking, the
researchers note, with leaner participants and nonsmokers showing a
more robust triglyceride lowering response with simvastatin.

"Studies are underway to identify specific polymorphisms in a number
of candidate genes that should account for some of these
differential LDL responses to simvastatin," Dr. Simon said.

"It may be possible to customize drug therapy for (hyperlipidemia)
and other disorders based on an individual's specific phenotypic and
genetic traits," Dr. Simon concluded.

Am J Cardiol 2006;97:843-850

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The ratio of albumin to creatinine in random urine samples can be
used to identify pregnant women with type 1 diabetes who have
microalbuminuria, according to a report in the April Diabetes Care.

"Screening for the presence of microalbuminuria in early pregnancy
is of uppermost importance since early antihypertensive treatment
during pregnancy might reduce the prevalence of preeclampsia and
preterm delivery in these woman with a high risk of complications,"
Dr. Elisabeth R. Mathiesen from University Hospital of Copenhagen,
Denmark told Reuters Health.

Dr. Mathiesen and her colleagues investigated whether measurement of
the albumin-to-creatinine ratio in random urine samples could
replace 24-hour urine collection in screening for micro- and
macroalbuminuria in 119 pregnant women with type 1 diabetes.

There was an 80% correlation between the 24-hour urinary albumin
excretion and the albumin-to-creatinine ratio in random urine
samples, the authors report.

Fifteen of 16 women with an albumin excretion above 30 mg per 24
hours had an albumin-to-creatinine ratio above 2.5 mg/mmol, the
results indicate, and all nine women with macroalbuminuria (albumin
excretion >300 mg/24 hours) had an albumin-to-creatinine ratio above
25 mg/mmol.

In contrast, the researchers note, all 103 women with an albumin
excretion below 30 mg in 24 hours had an albumin-to-creatinine ratio
below 2.5 mg/mmol

While 24-hour urine samples are the gold standard for detection of
microalbuminuria, Dr. Mathiesen said, "The data from this paper
makes it possible to use the much easier albumin-to-creatinine ratio
in a random urine sample early in pregnancy."

Diabetes Care 2006;29:924-925

Long-term outcomes after transplantation of hearts from donors aged
50 years or older are broadly comparable to those achieved with
hearts from younger donors, according to Canadian researchers.

"This is good news for people who are waiting for a heart
transplant - knowing more than 20% of patients die waiting for a
heart," senior investigator Dr. Shaoha Wang told Reuters Health.

In the March/April issue of the Journal of Cardiac Surgery, Dr. Wang
and colleagues at the University of Alberta Hospital, Edmonton
report on a retrospective analysis of all 338 adult cardiac
transplants conducted at their institution over a 15-year period.

Of these, 284 involved hearts from donors aged less than 50 years
and the remaining 54 received hearts from older donors.

Recipients of hearts from older donors were more likely to have
diabetes (33% versus 19%), renal failure (30% versus 16%) and
dialysis (3% versus 9%).

There were no between-group differences in factors including ICU and
postoperative stay and rejection episodes. However, mortality at 30
days was significantly higher in those with hearts from older donors
(17% versus 7%).

Nevertheless, at 1 year, actuarial survival rates were similar (74%
versus 87%). This was also true at 5 years (69% versus 76%) and at
10 years (58% versus 59%).

Pretransplant diabetes was the sole predictor of long-term survival
(hazard ratio, 1.659).

Despite increased perioperative mortality, Dr. Wang concluded, "we
could save more lives if we could expand the donor pool by using
older donors - with good long-term results."

J Card Surg 2006;21:117-124

Care for adults in Europe born with congenital heart disease needs
to be improved because there are not enough specialists and an
increasing number of patients, according to a survey released on
Wednesday.

The Euro Heart Survey on Adult Congenital Heart Disease, conducted
by researchers from Belgium, the Netherlands, Germany and
Switzerland, analyzed care for congenital heart disease patients
from data provided by 71 centers across Europe.

"We can definitely say that the provision of care overall is
suboptimal and there is much room for improvement," said Dr. Philip
Moons of the Catholic University of Leuven in Belgium.

"Our findings suggest that the number of adequately equipped centers
is too limited to support the more than 1.2 million adults with
congenital heart disease in Europe," Dr. Moons, the lead author of
the report, added in a statement.

Dr. Moons and his team said they could not draw conclusions about
care in individual nations because they did not receive information
from centers in all countries.

But the survey, published online by the European Heart Journal,
showed that many specialist centers did not perform the recommended
minimum number of congenital heart operations a year and did not
have specialist nurses on staff.

The researchers said a referral center should have at least one, and
preferably two, cardiologists trained in adult congenital heart
disease. Specialist centers should provide care in connection with
pediatric cardiology and/or congenital cardiac surgery.

Ideally, surgeons should perform 125 operations a year, with a
minimum of 50 for adult congenital heart disease, they added. There
should also be at least one nurse specialist trained in the care of
adult congenital heart disease patients, according to the
recommendations.

"If we are fully to realize the benefits of cardiac surgery that can
now be performed in infants and children, healthcare professionals
must apply continuous effort to implement these recommendations,"
Dr. Moons added.

Eur Heart J 2006

Treatment of intracranial aneurysms with the Matrix coil (Boston
Scientific, Natick, MA), which has a platinum core with a polymer
coating, is associated with poorer treatment outcome compared with
bare platinum coils, neurosurgeons at Roosevelt Hospital in New York
City report in the April issue of Stroke.

Dr. Yasunari Niimi and colleagues treated 74 intracranial aneurysms
in 70 patients with the Matrix coil. There were 32 ruptured
aneurysms that required acute treatment.

Complete class 1 aneurysm occlusion was achieved in 13 aneurysms
(17.6%), class 2 neck remnant occlusion in 40.5% and class 3
incomplete occlusion occurred in 41.9% of patients. Procedure-
related mortality and morbidity rates were both 1.4%.

Angiographic follow-up at one year was available for 47 aneurysms
(63.5%). The overall recanalization rate was 54.3%, with
recanalization in 25% of very small aneurysms (less than 5 mm), 33%
in small aneurysms (less than 10 mm) and 63% in aneurysms of small
size and wide width. Recanalization was achieved in 82% of very
large aneurysms (10 mm to 25 mm). Ten aneurysms (21.3%) required
repeat treatment.

At 15 months follow-up, 87% of patients had Gleason Outcome Scale
scores of 4 to 5.

Recanalization rates were worse with the Matrix coil than rates
reported for bare platinum coils, Dr. Niimi told Reuters Health. "We
use bare platinum coils and hydrogel-coated coils ... We do not use
Matrix coils any more."

Matrix coils resulted in less dense packing and less complete
occlusion of aneurysms compared with bare platinum coils. Dr. Niimi
commented that "this is especially worrisome when treating ruptured
aneurysms that may not be well protected from early rebleeding."

Stroke 2006;37:1028-1032

Makers of implanted heart devices should better track potential
safety problems and directly notify patients whose devices might
malfunction, a physician group said in guidelines proposed on
Wednesday.

Regulators also should improve surveillance of implanted
cardioverter defibrillators (ICDs) and pacemakers and use simple
language to explain safety issues, the Heart Rhythm Society said.

"We believe these draft guidelines are an important step towards
strengthening patient and physician knowledge, confidence and
trust," Dr. Anne Curtis, president of the society, said in a
statement.

The recommendations were a response to concerns about the handling
of problems identified with devices from various makers. Guidant
Corp. in particular drew criticism for failing to make public for
three years a potential problem with some ICDs.

Medtronic Inc. and St. Jude Medical Inc. also make ICDs.

The group said physicians should inform patients about the expected
performance of the devices and the chances of a malfunction. When
deciding how to respond to a safety warning, doctors should consider
the risks of removing and replacing a device.

To identify abnormal devices earlier, manufacturers should expand
the use of wireless and remote monitoring technologies, the group
said. It also urged companies to use independent panels of experts
to analyze device performance and to send patients a standard form
to alert them to potential problems.

Congress should provide additional funding for the Food and Drug
Administration to bolster its tracking of devices after they are
approved for sale, the group said.

The Heart Rhythm Society said it would take comments on the proposed
guidelines through May 30.

Transcatheter closure of patent foramen ovale (PFO) abolishes right-
to-left shunting and reduces aura migraine headaches, according to a
report in the April American Heart Journal.

Previous studies have shown a significant improvement in migraine
headache with aura after transcatheter PFO closure, the authors
explain, but the mechanism behind this effect is unknown.

Dr. Alessandro Giardini from the University of Bologna, Italy and
colleagues examined factors responsible for migraine headache with
aura in patients with PFO and assessed the mechanisms through which
PFO closure leads to an improvement in such headaches.

Compared to PFO patients without migraine headache, the authors
report, those with headache had a higher prevalence of spontaneous
and Valsalva-induced right-to-left shunt and a higher prevalence of
spontaneous large shunt both at transesophageal echocardiography and
at transcranial Doppler studies.

Patients with headache also had more complex atrial septal anatomy
and more often had an associated thrombophilia than patients without
headache, the results indicate.

Thirty-two of 35 patients experienced either complete resolution or
significant improvement in their headaches after the procedure, the
researchers note. None of the three patients who did not improve
after the procedure had a residual shunt at transesophageal
echocardiography.

"In patients with migraine headache with aura," the investigators
write, "the mechanisms that link right-to-left shunt to headache are
unknown."

"Paradoxical embolization of small-sized venous thrombus or platelet
aggregate reasonably seems to be the leading mechanism precipitating
migraine headache with aura in patients with a PFO," the authors
conclude. "Transcatheter defect closure seems to be an effective and
safe means to treat migraine headache with aura in patients with
PFO."

Am Heart J 2006;151:922.e1-922.e5

Adults who do not experience the normal nocturnal decrease in blood
pressure -- so-called nondippers -- are at increased risk for
deterioration of renal function, independent of baseline renal
function, blood pressure, and other risk factors for renal
impairment.

In a report of the study in the April 24th Archives of Internal
Medicine, researchers note that "most healthy people exhibit a
decrease in systolic BP at night. A drop of less than 10% from mean
daytime values (nondipping) is associated with chronic kidney
disease, insulin resistance, and cardiovascular events."

However, it's unclear whether nondipping status precedes a decline
in renal function.

Dr. Daniel J. Brotman from Johns Hopkins Hospital in Baltimore and
colleagues at the Cleveland Clinic investigated this issue in 322
patients, most of whom had normal renal function at baseline. One
hundred thirty-seven were dippers and 185 were nondippers.

During a median follow up of 3.2 years, the glomerular filtration
rate (GFR) remained stable among dippers (mean change, 1.3%) but
declined significantly among nondippers (mean change, -15.9%), the
researchers observed.

They also noted an increase of more than 50% in creatinine levels in
32 nondippers (17.3%) compared with only two dippers (1.5%).

These findings persisted after "rigorous adjustment" for other
predictors of GFR decline, the authors note.

In this study, Dr. Brotman told Reuters Health, "lack of a drop in
systolic blood pressure at night was a stronger predictor of decline
in renal function over follow-up than all 'traditional' predictors
of renal function decline, including diabetes and hypertension. This
relationship was independent of average blood pressure."

Further studies, the team concludes, "to elucidate the mechanisms
responsible for impaired diurnal BP variation among patients with
and without renal disease may clarify the pathogenesis of chronic
kidney disease in the general population and the associated
cardiovascular morbidity."

Arch Intern Med 2006;166:846-852

The prevalence of diabetes is significantly higher in patients with
schizophrenia or schizoaffective disorder relative to the general
population -- irrespective of the use of, or type of, antipsychotic
medication -- according to results of a Dutch study.

In the April issue of Diabetes Care, investigators report that oral
glucose tolerance tests in 200 mainly Caucasian adults with
schizophrenia or schizoaffective disorder showed that 14 (7%) had
hyperglycemia -- 3 had impaired fasting glucose and 11 had impaired
glucose tolerance. Moreover, 29 (14.5%) were diabetic, of whom 13
were newly diagnosed with the disease.

"Compared with a 1.5% prevalence of diabetes in the age-matched
general Dutch population, the prevalence of identified cases was
significantly increased in the study population," Dr. Dan Cohen from
University Medical Center Utrecht, the Netherlands and colleagues
note in their report.

"The increased prevalence begins early, certainly after 30 and
possible even earlier," Dr. Cohen noted in comments to Reuters
Health. "This suggests that an early aging effect is present in the
population of patients with schizophrenia or schizoaffective
disorder," he and his colleagues note in their report.

As mentioned, insulin resistance was higher in the study population
as a whole regardless of the use of antipsychotic medication and, if
used, irrespective of its type (typical or atypical). No evidence of
beta-cell defects was found.

These findings, Dr. Cohen and colleagues say, support a body of
literature linking disturbances in glucose metabolism to
schizophrenia and support "measurement of fasting glucose in all
patients with schizophrenia, irrespective of prescribed
antipsychotic drug."

"Monitoring of glycemic control is indicated above the age of 30 and
advised under 30 years in all patients with antipsychotic
medication, both typical and atypical," Dr. Cohen added.

Diabetes Care 2006;29:786-791

When taken in combination to prevent ischemic stroke,
antiplatelets, angiotensin-converting enzyme (ACE) inhibitors, and
statins reduce the severity of ischemic stroke if it occurs, Boston-
based investigators report in the April 25th issue of Neurology.

In an interview with Reuters Health, Dr. Magdy H. Selim from Beth
Israel Deaconess Medical Center said this "small preliminary study
provides a scientific rationale for combining these drugs. It shows
that if patients are on these drugs even before they suffer a
stroke, it makes their strokes much more mild and they can recover
better."

The study involved 179 patients presenting within 24 hours of stroke
onset. Sixty-nine were not taking any of the three drugs at stroke
onset; 47 were taking antiplatelet therapy only; 29 were taking
antiplatelets and ACE inhibitors; 14 were taking antiplatelets and
statins; and 20 were taking a combination of antiplatelets, ACE
inhibitors and statins.

According to Dr. Selim and colleagues, patients on triple therapy at
stroke onset had less severe strokes, determined by the NIH Stroke
Scale, shorter hospital stays, and better functional status upon
discharge than patients taking none, one, or two of the three drugs
before stroke onset.

At discharge, 65% of patients on triple therapy showed neurological
improvement from baseline, compared with 45% of those taking
antiplatelets plus ACE inhibitors, 43% of those taking antiplatelets
plus statins, 38% of those taking antiplatelets only, and 33% of
those taking none of the drugs.

At hospital discharge, 35% on triple therapy had no or only slight
disability compared with 17% of patients in the antiplatelet/ACE
group, 14% in the antiplatelet/statin group, 11% in the antiplatelet
only group and 10% in the no therapy group.

Imaging studies showed that while the amount of initial brain tissue
damage was roughly equal among the groups, on average, the volume of
brain tissue still at risk was significantly smaller among those
taking triple therapy.

"It's possible that these three drugs work synergistically to reduce
the amount of brain tissue that is damaged in the penumbra by
improving blood flow," Dr. Selim noted in a statement from the
American Academy of Neurology.

The authors of a related editorial say this "important study adds to
the growing evidence that statins and ACE inhibitors may be useful
as neuroprotective agents in the setting of acute ischemic stroke."

However, the study authors and editorialists caution, that these
findings need to be validated in large controlled studies before
statins and ACE inhibitors can be recommended for all people at risk
for stroke or for the treatment of acute stroke.

Neurology 2006;66:1135,1153-1158

Patients with high plasma aldosterone, but who do not meet
diagnostic criteria for primary aldosteronism, are more likely to
have resistant hypertension than patients with low aldosterone
levels, Italian researchers report.

"The clinical course of these patients is indistinguishable from
that of hypertensives with clinically diagnosed IHA (idiopathic
aldosteronism)," Dr. Andrea Semplicini of Policlinico Universitario
in Padova and colleagues write. "The data cast doubts on the
diagnosis of IHA based on the currently accepted criteria and
suggest that primary aldosteronism is part of a large continuum,
spanning from low renin EH (essential hypertension) to adrenal
hyperplasia."

Thirty percent of hypertensive patients are treatment-resistant,
meaning treatment with at least three classes of antihypertensive
drugs has failed to bring their blood pressure below 140/90 mm Hg,
Dr. Semplicini and his team note in the American Journal of
Hypertension for April.

To determine if resistant hypertension might be more common among
patients with relatively high aldosterone levels, the researchers
analyzed 149 patients with aldosterone-renin-ratios (ARRs) of 25
(ng/dL)/(ng/ml/h) or greater and plasma aldosterone of 12 ng/dL or
above. Fifty-eight were diagnosed with primary aldosteronism, while
the remaining 91, who did not meet diagnostic criteria for that
condition, were described as having aldosterone-associated
hypertension (AAH). The researchers compared them to 160 patients
with essential hypertension who had aldosterone levels below 12
ng/dL.

After a 22-month follow-up, 41.4% of patients with IHA achieved
blood pressure below 140/90 mm Hg, compared to 38.5% of patients
with AAH and 54.0% of those with essential hypertension. On average,
IHA and AAH patients had higher diastolic BP compared to EH patients.

"Our results, which emphasize the role of relative aldosterone
excess in causing treatment resistance beyond classic primary
aldosteronism, suggest the need of clinical trials with aldosterone
antagonists, possibly with less antiandrogenic and antiprogesteronic
effects than spironolactone, such as eplerenone, even in patients
with high aldosterone levels but without confirmed primary
aldosteronism," the researchers conclude.

Am J Hypertens 2006;19:373-379

Presumably due to their greater complexity, implantable cardioverter-
defibrillators (ICDs) are much more likely than pacemakers to
malfunction, new research shows. Still, the absolute risk of
malfunction with either type of device is very low and for
appropriately selected patients the benefits far outweigh the risks.

The report, which appears in the Journal of the American Medical
Association for April 26, also indicates that in the last decade,
malfunction rates have dropped for pacemakers, but increased for
ICDs. The authors speculate that this may be because pacemakers are
an older, developed technology, whereas ICDs are still evolving. The
good news is that in recent years, malfunction rates for ICDs seem
to have declined.

In a related study, appearing in the same journal, researchers show
that ICD replacement in response to device advisories is often
linked to serious complications, including death.

Dr. William H. Maisel, from Beth Israel Deaconess Medical Center in
Boston, and colleagues reviewed pacemaker and ICD reports submitted
to the US Food and Drug Administration between 1990 and 2002 to
assess replacement rates due to malfunction. In a similar analysis,
Dr. Maisel reviews data from international device registries.

Of the 2.25 million pacemakers implanted in the US during the study
period, 8834 were removed due to malfunction. For ICDs, 415,780 were
implanted and 8489 were removed. Half of all device failures related
to battery/capacitor abnormalities and electrical issues.

The overall annual malfunction replacement rate per 1000 implants
was 20.7 for ICDs compared with just 4.6 for pacemakers (p < 0.001).
Thirty deaths in pacemaker patients and 31 in ICD patients were
attributed to device malfunction.

For pacemakers, the malfunction rate peaked in 1993 at 9.0
replacements per 1000 implants. From that point, the rate fell
steadily to a low of 1.4 replacements per 1000 implants in 2002.

By contrast, for ICDs, the malfunction replacement rate per 1000
implants dropped from 38.6 in 1993 to 7.9 in 1996, only to climb
again to 36.4 in 2001.

However, Dr. Maisel told Reuters Health, "when I reviewed
international device registries, which included data through 2004,
there was a reassuring trend with a marked reduction in ICD
malfunction rates for 2003 and 2004 ... This suggests that ICD
technology has matured."

In the second study, Dr. Andrew D. Krahn, from the London Health
Sciences Centre in Ontario, Canada, and colleagues assessed the
complications that occur when ICDs were replaced in response to
device advisories. A total of 17 ICD implanting centers were
surveyed to assess the complications that arose from replacements
due to advisories from October 2004 to October 2005.

Of the 2915 patients who had recalled devices, 533 underwent
replacement an average of 26.5 months after initial
implantation. "Indications for device replacement in the context of
the advisories included pacing dependence and previously appropriate
shocks... patient preference ... and secondary prevention indication
for ICD."

During an average follow-up period of 2.7 months, the complication
rate for ICD replacement was 8.1%. Moreover, the bulk of the
complications were considered major and required reoperation. Two
patients died when their replaced device had to be removed for
pocket infection.

"For physicians, it's important for them to have this background
knowledge to understand that these devices can malfunction. They're
not required to, but it certainly helps postmarket monitoring, if
they report device malfunctions to manufacturers and the FDA when
they occur," Dr. Maisel said.

In a related editorial, Dr. Bruce L. Wilkoff, from the Cleveland
Clinic Foundation, comments that "these investigations contribute
new data to the information mosaic involving pacemakers and ICDs and
should enable clinicians and patients to make better informed
decisions about these devices."

JAMA 2006;295:1901-1911,1929-1934,1944-1946

Lixivaptan, a selective antagonist of arginine vasopressin (AVP),
increases solute-free water excretion in patients with chronic heart
failure (CHF), according to a report in the April 18th Journal of
the American College of Cardiology.

The role of AVP in the water retention and dilutional hyponatremia
that accompany heart failure remains controversial, the authors
explain, but AVP antagonists have been shown to reverse these
abnormalities in experimental models of CHF.

Dr. William T. Abraham from The Ohio State University Heart Center,
Columbus, Ohio and colleagues evaluated the effects of various doses
of lixivaptan in 42 patients with NYHA functional class II or III
heart failure.

At doses greater than 10 mg, lixivaptan induced significant
increases in 24-hour urine volume, rising from 1.8 liters with
placebo to 3.9 liters after a 400-mg dose of lixivaptan, the maximum
tested, the researchers report.

All patients administered lixivaptan showed significantly lower
urinary osmolality than patients given placebo, the researchers note.

Lixivaptan dramatically increased solute-free water excretion during
the first 2 hours after dosing, the report indicates, and serum
osmolality was significantly higher after treatment with lixivaptan
than after placebo treatment.

These changes were apparent despite increases in AVP concentrations
seen after administration of higher doses of lixivaptan, the
investigators say. Other hormone levels did not change significantly.

"These findings suggest a role for AVP in the water retention
associated with heart failure and demonstrate the potential utility
of AVP antagonists for its treatment," the investigators
conclude. "The effect of such agents on heart failure outcomes
requires evaluation in large-scale morbidity and mortality studies,"
they add.

J Am Coll Cardiol 2006;47:1615-1621