HTAC Report on Coronary Artery Disease Screening

The Minnesota Health Technology Advisory Committee (HTAC) has issued an evidence-based report on C-reactive protein (CRP) testing to screen for coronary artery disease (CAD). The full report is available online atwww.health.state.mn.us/htac.

CAD accounted for one of every five deaths in 1998, and it is the leading cause of premature and permanent disability. Numerous studies suggest that inflammatory changes in the vessel walls initiate atherosclerosis. As the disease progresses, the atherosclerotic plaques erode, become unstable, and eventually rupture causing thrombosis, unstable angina, and myocardial infarction. This link between chronic, low-grade inflammation and CAD has led researchers to investigate serum inflammatory markers, particularly acute-phase reactants, to determine whether their appearance correlates with the presence or extent of CAD.

Researchers have hypothesized that CRP, the classic acute-phase reactant, may provide an adjunctive method for assessment of cardiovascular risk. Several studies indicate that plasma levels of CRP are a strong independent risk factor of future myocardial infarction, stroke, and vascular death among people without clinically recognized cardiovascular disease.

After a review of the evidence, HTAC concluded that CRP is a non-specific marker of inflammation and that it is unclear whether CRP is a risk factor for CAD and a potential target for intervention. The committee recommends that the results of CRP testing be analyzed in conjunction with the results of standard diagnostic tests, medical history, and clinical findings, because its efficacy as a stand-alone test has not been proved.

FDA Approvals

• Commit Lozenge. The Commit Lozenge is a nicotine-replacement product approved by the U.S. Food and Drug Administration (FDA) for over-the-counter sale. The lozenges are available with different dosages of nicotine, allowing the smoker to choose the strength of nicotine needed during an attempt to stop smoking.

A strength indicator is included with the lozenges and gives directions on what strength of the lozenge to use within or after 30 minutes of waking, and how often to use the lozenges. The patient should use fewer and fewer lozenges during the 12-week program until he or she is completely nicotine-free. Patients should not smoke while using nicotine-replacement products. Persons who have a history of heart disease, who have an irregular heartbeat, who have had a recent heart attack, who are taking antidepressants or asthma medications, and who are pregnant or breastfeeding are encouraged to talk with their physician before using the product.

ACOG Guidelines on Obstetric Analgesia, Anesthesia

The Committee on Practice Bulletins of the American College of Obstetricians and Gynecologists (ACOG) has issued guidelines on obstetric analgesia and anesthesia. ACOG Practice Bulletin No. 36 appears in the July 2002 issue of Obstetrics and Gynecology.

Uterine contractions and cervical dilation result in visceral pain, and as labor progresses, the descent of the fetus's head and subsequent pressure on the pelvic floor, vagina, and perineum generate somatic pain transmitted by the pudendal nerve. Ideally, pain relief will ameliorate both sources.

The ACOG guidelines recommend physicians make regional analgesia available during labor. Women with preeclampsia are potential candidates, unless a contraindication is present, as are women with platelet counts of 50,000 to 100,000 cells per mm³ (50 to 100 × 10⁹ per L), although a platelet count is not necessary in patients without complications.

Contraindications include refractory maternal hypotension, maternal coagulopathy, maternal use of a once-daily dose of low-molecular-weight heparin within 72 hours, untreated maternal bacteremia, skin infection at the site of needle placement, and increased intracranial pressure caused by a mass lesion.

Parenteral pain medications for labor pain decrease fetal heart rate and can limit the physician's ability to interpret the fetal heart rate tracing, according to the guidelines.