 | What Your Doctor Is Reading | | |
Update From the Medical Journals: February 2007
February 28, 2007  By Mary Pickett, M.D.
Harvard Medical School What's the latest news in the medical journals this month? Find out what your doctor is reading. New Way To Predict a Woman's Heart Risk In the February 14 issue of the Journal of the American Medical Association (JAMA), cardiologists reported a new way to estimate a woman's heart disease risk. Until now, doctor's assigned points to risk factors such as older age, smoking, diabetes, high cholesterol, and high blood pressure. This point total has been called the "Framingham 10-year Risk Score." However, the score was less accurate for women than it was for men, since the risk factors were originally identified by studies of male patients. The new calculation is called the "Reynolds Risk Score" and was developed by doctors who studied more than 24,000 women for ten years. It's based on the relationship between certain risk factors and the chance that a woman would have a heart attack, a stroke or need angina treatment (such as an artery stent or heart surgery). An individual score predicts what percent of women with risk factors identical to yours would be expected to have one of these events during the next ten years. In order to use the Reynolds Risk Score, a woman needs to know her: - Total cholesterol and HDL (high density lipoprotein or "good" cholesterol)
- Blood pressure
- The results of a blood test to measure inflammation, called high sensitivity C reactive protein (hsCRP)
- Family history of heart disease, which is a particularly important risk factor for women
Because this risk calculation requires the expense of an extra blood test, doctors may hesitate to use it, even though it's more accurate than earlier risk prediction tools. If you're being treated for high cholesterol, it may be worth getting your hsCRP tested so your doctor can "tweak" your treatment plan based on this more accurate calculation. Go to www.reynoldsriskscore.org to find out your risk score. Back to top Experts Release Guidelines for People with Pre-diabetes The American Diabetes Association (ADA) published guidelines on February 27 for treating individuals with "pre-diabetes." (They appear in the March issue of the journal, Diabetes Care.) Pre-diabetes is diagnosed by blood tests after an overnight fast. The tests show a glucose level that is high, but not high enough to indicate diabetes. If you have pre-diabetes, you have about a 10% chance of developing diabetes within one year, and roughly a 70% chance of developing diabetes during your lifetime. With the onset of diabetes, your risk for heart disease and stroke increase sharply, so it's important to delay or prevent diabetes if possible. Until now, doctors have made individualized recommendations to patients with pre-diabetes, without the benefit of expert guidelines. According to the new ADA guidelines, people with pre-diabetes who are obese should aim to lose 5% to 10% of their body weight through diet and at least 30 minutes of exercise a day. This can help decrease the chance of pre-diabetes becoming full-blown diabetes during the next three years by nearly 60%. People who have pre-diabetes and one or more of the following risk factors increase their risk of developing diabetes: - Age 59 and younger
- Obesity (a body mass index (BMI) of 35 or higher
- A family history of diabetes in a parent or sibling
- High triglycerides
- Low HDL cholesterol
- High blood pressure
- A1C test >6%
People who fall into this category should consider drug treatment with metformin (Glucophage) in addition to diet and exercise, according to the guidelines. An oral glucose tolerance test can help identify people who are most likely to benefit from medication. Your doctor can help arrange for this test. Back to top Inhaler Treatments for COPD Go Head-to-Head On February 22, the New England Journal of Medicine published a large study comparing several inhaler treatments for chronic obstructive pulmonary disease (COPD). COPD includes emphysema and chronic bronchitis and is common among smokers. Coughing and shortness of breath from COPD can be relieved with short-acting inhalers, such as ipratropium (Atrovent) or albuterol (Proventil). They are called bronchodilators and help relax the muscles around the airways. If these don't control symptoms, doctors often prescribe an inhaled steroid or a long-acting bronchodilator, such as salmeterol (Serevent). Although these second-choice treatments sometimes improve patients' symptoms, doctors didn't know whether either inhaled steroid or long-acting bronchodilators help people with COPD live longer. This is important to know, particularly since long-acting inhalers called beta-agonists have caused a small number of excess deaths in groups of asthmatics. This current study included 6,112 patients who were randomly assigned to treatment with one of four inhaler types: placebo, long-acting bronchodilator (salmeterol), an inhaled steroid (fluticasone or Flovent), or an inhaler with salmeterol and fluticasone together (Advair). The three-year study showed only minimal differences in mortality between the groups, so survival did not significantly change with any of the treatments. The combination inhaler treatment seemed to allow slightly more time between flare-ups of COPD, and improved lung function tests slightly. Inhaled steroid treatments seemed to put patients at slightly higher risk for pneumonia, which is not surprising since steroids can interfere with immune system function. The bottom line is that a combination inhaler, such as Advair is a better choice than a pure steroid inhaler for patients whose COPD symptoms are not relieved by short-acting inhalers. The benefits from a combination inhaler are limited, however, and survival is not significantly changed. Since inhalers are costly (about $50 each, per month of use), these treatments may not be worth the cost for some patients, unless there are clear-cut improvements to their symptoms. Back to top More News in Brief - New Childhood Vaccine has Potential Complication. On February 13, the U.S. Food and Drug Administration (FDA) issued a public health notice inviting reports of a possible complication with the rotavirus vaccine that it is monitoring. About 3.5 million infants in the U.S. have received the vaccine, which became available a year ago. An earlier version of the vaccine appeared to cause a type of intestinal blockage called intussusception in a few individuals. Intussusception occurs when the intestine folds around itself to make a double layer — much like rolling up a cuff on a shirt sleeve. During testing of the new version of the vaccine, there were no reports of intussusception. Even so, the FDA has been on the alert for cases. So far, 28 intussusception cases following the vaccination have been reported to the FDA. This small number of cases may be a complete coincidence because intussusception sometimes happen out of the blue. Still, the FDA is requesting that doctors and parents watch for symptoms of stomach pain, vomiting, diarrhea, blood in their infant's stool or changes in their baby's bowel movements within several weeks of vaccination, and report them to their doctor.
- Pre-Diabetes Raises Women's Risk for some Cancers. Korean researchers used Swedish population data to identify a link between pre-diabetes and the risk for some types of cancer in women. Their study was published online on February 27 in the March issue of Diabetes Care. Fasting blood sugar tests were available for more than 64,000 men and women in Sweden. Slightly more than 3,000 of the women had mildly elevated fasting glucose tests, a sign of pre-diabetes. Among women with elevated glucose, there was a higher rate than expected of uterine cancer, bladder cancer, malignant melanoma, and cancer of the pancreas. Previous studies have shown increased cancer rates for diabetics. This study shows that the risk begins to rise even before diabetes has fully developed. The reason behind the pre-diabetes and cancer connection is not known. In this study, men did not have a higher rate of cancer overall if their glucose was mildly elevated.
Back to top Mary Pickett, M.D., is a lecturer for Harvard Medical School and an assistant professor of medicine at Oregon Health & Science University. At OHSU, she is a director of student programs and she oversees teaching of students and medical residents. She practices general internal medicine in Portland, Ore.
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