Lowering LDL Cholesterol Levels Benefits Patients with Heart Disease

(71st Annual Scientific Sessions of the American Heart Association) Results from the Atorvastatin Versus Revascularization Treatments (AVERT) trial revealed that patients with stable coronary artery disease receive significant cardiovascular benefit through aggressive reduction of low-density lipoprotein (LDL) cholesterol levels to less than 100 mg per dL (2.6 mmol per L). During the 18-month trial, 341 patients were randomized to receive either 80 mg of atorvastatin per day (Lipitor) or to undergo angioplasty followed by usual care. At the beginning of the study, all of the patients had 50 percent or greater narrowing of at least one coronary artery, had no symptoms or mild to moderate chest pain, had relatively normal left ventricular function and were candidates for angioplasty. The patients who received atorvastatin achieved a mean LDL level of 77 mg per dL (2.0 mmol per L), compared with a mean level of 119 mg per dL (3.1 mmol per L) in patients in the angioplasty and usual care group. Eighty-seven percent of the patients who received atorvastatin remained on the medication without any coronary events during the study period, instead of undergoing angioplasty as was originally intended. During the trial, 13 percent of patients treated with atorvastatin had a cardiovascular event, compared with 21 percent of patients receiving angioplasty and usual care. In the angioplasty group, usual care resulted in one third of patients receiving stents and 71 percent of patients receiving statin therapy.—bertram pitt, m.d., et al., University of Michigan School of Medicine, Ann Arbor, Michigan.

New Treatment Regimen Is Effective in Patients with Heart Failure

(American Heart Association) A significant reduction in total mortality in patients with severe heart failure can be obtained with the addition of spironolactone (Aldactone) to standard treatment regimens (including an angiotensin-converting enzyme inhibitor), according to results of a multi-center, randomized, double-blind trial conducted in 15 countries. The Randomized Aldactone Evaluation Study (RALES) included 1,663 patients who had severe heart failure with systolic left ventricular dysfunction. All of the patients in the study had New York Heart Association class III or class IV heart disease. Among the 1,663 patients, there were 372 deaths in the group receiving placebo and 283 deaths in the patients receiving spironolactone, indicating a 27 percent reduction in total mortality in the group receiving spironolactone. A decrease was also noted in the number of nonfatal hospitalizations in the patients receiving the addition of spironolactone. The RALES study was stopped early, because the results were so statistically and clinically significant that it was determined it would be unethical to continue.—bertram pitt, m.d., et al., University of Michigan School of Medicine, Ann Arbor, Michigan.

Study Evaluates Low-Molecular-Weight Heparin in Unstable CAD

(48th Annual Scientific Sessions of the American College of Cardiology) Treatment with dalteparin (Fragmin) injection for up to 45 days can reduce the incidence of death or myocardial infarction in patients with unstable coronary artery disease, according to results of the Fast Revascularization During Instability in Coronary Artery Disease (FRISC II) trial. The FRISC trial compared the efficacy of prolonged (three months) treatment with dalteparin with short-term (five days) dalteparin treatment. During the first five to seven days, all 2,267 patients received 120 IU per kg of dalteparin every 12 hours. During the long-term double-blind phase, 2,105 patients were randomized to treatment with either dalteparin or placebo. After 90 days of treatment with dalteparin, the difference in the incidence of death/myocardial infarction in the treatment groups was not significant (6.7 percent in patients receiving dalteparin versus 8.0 percent in those receiving placebo); however, the difference during the first 45 days of treatment was significant (3.7 percent in patients receiving dalteparin versus 6.5 percent in those receiving placebo). The investigators believe that the results of this study provide physicians and their patients the flexibility to develop further treatment strategies.—lars wallentin, et al., Uppsala University Hospital, Sweden.

Race, Gender Affect Which Treatment Is Selected for Angina Symptoms

(American College of Cardiology) A patient's race and gender can influence the physician's choice of treatment for chest pain. This is the conclusion of a study of 720 physicians between the ages of 55 and 70 years who were randomized to view videos of one of eight actors playing patients who differed in race (black or white) and gender, and who presented with identical angina symptoms, risk factors for myocardial infarction and results of exercise stress tests. After viewing the video, the physicians were asked to recommend further diagnostic evaluations for the patients, such as cardiac catheterization. Analysis of the recommendations showed that race and gender played a significant role in determining which patients would have been referred for cardiac catheterization. Women and blacks in general were less likely to be referred for the diagnostic procedure than white men. Older black women had the lowest rate of cardiac catheterization referral. The investigators believe that physician decision-making is an important factor in explaining differences by patient race and gender in the treatment of coronary artery disease.—kevin a. schulman, m.d., et al., Georgetown University Medical Center, Washington, D.C.

Gender Differences Are Reflected in Cost of Heart Surgery

(Annual Meeting of the American Society of Anesthesiologists) Results of a study of 550 patients undergoing coronary artery bypass graft (CABG) surgery in 1997 indicate that the cost of undergoing CABG is 20 percent higher in women than in men. The amount of time that women spent on mechanical ventilation following surgery in the study was 19.8 hours versus 12.9 hours for the men. Time spent in the hospital following surgery was 7.3 days for women and 5.7 days for the men. There were no significant differences between the male and female subjects in the severity of coronary disease before surgery. The investigators are conducting more research to determine why this difference in cost exists.—manual l. fontes, m.d., et al., Yale University, New Haven, Connecticut.

Botulinum Toxin A Shows Promise in Treatment of Migraine Headache

(41st Annual Scientific Meeting of the American Association for the Study of Headache) Botulinum toxin type A (Botox) shows promise in the treatment of patients with migraine headache, according to an analysis of data from a random sampling of 96 patients who received the treatment in a cosmetic surgery clinic, a neurology clinic or an otolaryngology practice. The botulinum toxin was injected into the glabellar, temporalis, frontalis, corrugator and occipital muscles. Forty-nine (51 percent) of the patients had a complete response (elimination of headaches); 27 (28 percent) had partial improvement (at least a 50 percent reduction in the frequency or severity of headaches); and 20 (21 percent) had no response. The patients with a partial response had more frequent headaches at baseline, compared with the complete responders. Adverse effects include transient local pain at the injection site and ecchymosis. The investigators note that preliminary results also showed a benefit in acute migraine intervention.—william j. binder, m.d., et al, University of California School of Medicine, Los Angeles, California.