Will Boggs Md

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

NEW YORK - While the new International Classification of Diseases, Tenth Revision, Clinical

Modification (ICD-10-CM) codes offer greater diagnostic precision, their implementation will require training of clinicians, coders, and other staff to minimize payment denials or delays from both public and private payers.

Brian Outland and colleagues from the American College of Physicians in Washington, D.C., outline some of the promises and challenges of ICD-10-CM implementation in a report online Sept. 22 in Annals of Internal Medicine.

Although completed and endorsed by the World Health Assembly in 1990, ICD-10-CM's implementation date has repeatedly been delayed, and was scheduled to take effect on Oct. 1.

The authors suggest that "the newer coding system will produce data that will indicate the clinical trajectory and other factors that will enable the data to be used in meaningful ways to better understand complications, design robust algorithms for clinical decision support, and track outcomes. Having these details built into the codes will decrease the need for health care providers to include supporting documentation with claims."

The new ICD-10-CM alphanumeric codes will contain as many as seven characters that specify categories, subcategories, laterality, severity and other features.

The use of codes that are not specific enough can result in payment denials or delays, so practices will need to keep current on payer reimbursement policies to ensure the reporting of ICD-10-CM codes that support reimbursement, the authors note.

The cost for the training of clinicians and staffs will depend on practice size, specialty, the method of training, current documentation quality, and technology readiness and availability.

Dr. Susan H. Fenton from UTHealth School of Biomedical Informatics in Houston, Texas, said by email, "One of the thoughts I cannot get away from is that the U.S. is trying to manage a 21st-century, rapidly evolving healthcare system with a 1970s technology. I can think of little else in healthcare that has remained as static since the 1970s."

"The diagnostic system added lots of codes, but the basic structure is the same," she said.

"Certainly, with more detail such as laterality, as well as first encounter, subsequent encounter, and sequelae, it will be much easier to track care for specific conditions across providers," Dr. Fenton said. "I think the issue of claims denials will have to play out over time."

Resources and tools from the Centers for Medicare & Medicaid Services (CMS) can be found online at www.roadto10.org.

The American College of Physicians also has helpful information available at www.acponline.org/ICD10.

Outland did not respond to a request for comment.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Catheter ablation is favored for the management of most forms of supraventricular tachycardia (SVT) in adults, according to revised guidelines from the American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS).

SVT affects 2.25 in 1000 individuals in the general population, with about 89,000 new cases of paroxysmal SVT (PSVT) per year. Women are twice as likely as men and individuals older than 65 are more than five times as likely as younger people to develop PSVT.

To provide a contemporary guideline for managing adults with all types of SVT except atrial fibrillation, ACC/AHA/HRS have now updated their 2003 guidelines.

Included are recommendations for managing sinus tachyarrhythmias, nonsinus focal atrial tachycardia and multifocal atrial tachycardia (MAT), atrioventricular nodal reentrant tachycardia (AVNRT), manifest and concealed accessory pathways, atrial flutter, and junctional tachycardia.

"Despite a 12-year gap in the update for these guidelines, there have been very few advances in antiarrhythmic drug therapy to offer patients with SVT," Dr. Gregory F. Michaud, director of the Center for Advanced Management of Atrial Fibrillation at Brigham and Women's Hospital in Boston, said by email.

"Catheter ablation has taken a stronger foothold in the chronic treatment of SVT and as such many physicians and patients are opting for invasive therapy earlier in the course of therapy," said Dr. Michaud, who wasn't involved in the guidelines.

The guidelines recommend vagal maneuvers, various drugs, and/or cardioversion as acute treatments, depending on the specific cause of SVT.

For most forms of symptomatic SVT, including those of unknown mechanism, the guidelines recommend electrophysiological (EP) studies and catheter ablation as definitive treatment for patients willing to undergo them, especially if medical therapy is ineffective.

Cardiac mapping is performed during EP studies to identify the site of origin of the arrhythmia or areas of critical conduction to allow targeting of ablation.

"One exception is inappropriate sinus tachycardia (IST) for which a more effective drug, ivabradine, is now available in the United States," Dr. Michaud said. "Catheter ablation is generally ineffective for IST patients."

Besides evaluation and treatment of possible reversible causes of IST, the guidelines recommend ivabradine, beta blockers, or their combination.

"SVT is generally not a life-threatening condition and treatment is based on eliminating symptoms and improving patient quality of life," Dr. Michaud explained. "However, physicians should be aware of three conditions associated with SVT that may be serious. First, sudden death is associated with the WPW (Wolff-Parkinson-White) syndrome and these patients, even if asymptomatic, should be referred to a cardiac electrophysiologist to consider management options."

He continued, "Second, SVT can cause cardiomyopathy and heart failure when incessant, even if the patient is asymptomatic. These patients should also be referred to a cardiac electrophysiologist to consider definitive therapy.

Third, patients with atrial flutter should be considered for oral anticoagulation to prevent stroke using the CHADS-Vasc risk scoring system, just as you would for patients with atrial fibrillation."

Dr. Michaud added, "Putting aside cost as an issue, there is significant regional variability in the accessibility of electrophysiologists or cardiologists with arrhythmia expertise. In my area, for instance, electrophysiologists are plentiful, and patients with SVT are often sent to us directly for further evaluation and treatment. Furthermore, training in arrhythmia management has become the purview of clinical cardiac electrophysiology, and many recently trained cardiologists are not as comfortable as their predecessors in managing patients with SVT."

The full report appears in the September 23 Journal of the American College of Cardiology online and was copublished in Circulation and Heart Rhythm.

Dr. Richard L. Page and Dr. Jose A. Joglar, chair and vice chair of the writing committee, did not respond to a request for comments.

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."

NEW YORK - Atrial fibrillation (AF) is associated with an increased risk of dementia, especially in younger individuals, according to results from the Rotterdam Study.

"When we started this study, we hypothesized that the hazard of atrial fibrillation would be higher with longer exposure, but to find such a strong exposure-time association in younger participants was striking," said Dr. Frank J. Wolters from Erasmus Medical Center in Rotterdam, the Netherlands.

"It emphasizes that prevention of dementia doesn't start when people report to their physician with mild memory complaints, but years, if not decades before, by identifying those at risk and optimizing preventive strategies," he said by email.

An earlier report from the Rotterdam Study showed that AF is more prevalent in people with dementia, but the cross-sectional design did not allow conclusions regarding a causal relationship.

Dr. Wolters's team investigated the association between AF and dementia during a follow up of 20 years of nearly 6,200 participants in the Rotterdam Study.

About 5% of the participants had AF at baseline, and 15.3% of these individuals developed dementia during more than 81,000 person-years of follow-up.

Another 11.7% developed AF later, and 15.0% developed dementia during more than 79,000 person-years, the researchers report in JAMA Neurology, online September 21.

People who had AF at the start of the study had a 34% increased risk of dementia (compared with those who did not have prevalent AF), and people who developed AF during follow-up had a 23% increased risk of dementia (compared with those who did not have incident AF).

The association between AF and dementia was strongest in persons younger than the median age (67 years), and in these younger participants, the risk of dementia was higher with increasing duration of AF.

"As we found atrial fibrillation to increase the risk of dementia independent of clinical stroke, either chronic hypoperfusion or more acutely silent infarcts or perhaps cortical microinfarcts could account for the increased risk of dementia," Dr. Wolters said.

"A few observational studies have suggested beneficialeffect of treatment of atrial fibrillation on the risk of dementia, but more evidence on treatment efficacy is sorely needed. This includes insight into whether optimal treatment consists of anticoagulation, heart rhythm, or rate control," he noted.

"With regard to treatment of atrial fibrillation, until further evidence on efficacy becomes available, it is worth realizing that optimal adherence to current guidelines may contribute to prevention of cognitive decline in addition to prevention of stroke," Dr. Wolters added. "Although we found the strongest associations between atrial fibrillation and dementia for younger people, the need to determine treatment efficacy is just as profound in the elderly."

Dr. Sanjay Dixit, director of cardiac electrophysiology at Philadelphia VA Medical Center in Pennsylvania, said by email, "Although the association between AF and dementia has been shown, it's difficult to establish cause and effect. As I point out in my previous review, obstructive sleep apnea (OSA) is considered to be a major contributor to the development of neurocognitive decline and dementia. OSA is very common in the AF population and many consider this to be (a) risk factor in the development of AF. So the question remains whether AF is the cause of dementia or other co-morbidities such as OSA that frequently co-exist in the AF population."

"Look for AF in patients with dementia and also caution patients with AF of the possibility of developing this condition in the future," Dr. Dixit advised. "Since catheter ablation therapy has been shown to have better outcomes for long-term control of AF than drugs, physicians should discuss this with patients and consider referring them to cardiac electrophysiologists early in the course of the disease."

Dr. T. Jared Bunch, director of heart rhythm services for Intermountain Healthcare, Murray, Utah, said by email, "It is great to see another confirmatory study that found essentially the same thing we did 5 years ago. These data in aggregate make the likelihood of the association much more compelling."

"What is interesting in our subsequent work is the patients more sensitive to poor warfarin management (low times in therapeutic range) were at the highest relative risk of dementia compared to older patients," Dr. Bunch explained. "Now we all need to start to unravel the mechanisms behind it and find avenues of preventative treatment. The choice and manner of anticoagulant treatment is one and allowing faster heart rates is another."

Dr. Shih-An Chen and Dr. Tzu-Fan Chao from Taipei Veterans General Hospital, Taipei, Taiwan, who recently reported on the independent association between AF and dementia, struck a more cautious note.

"Only when a lower risk of dementia can be achieved by AF ablation in the prospective and randomized trial can we conclude that AF is the direct cause of dementia," they said in a joint email. "It should also be noted that the development of dementia is multifactorial, and AF only represents one of them."

NEW YORK - Perioperative beta-blocker use in patients with hypertension is associated with increased cardiovascular complications and mortality after noncardiac surgery, researchers from Denmark report.

"The consistency of the findings of increased risks associated with beta-blockers across numerous subgroups was an important finding," Dr. Mads Emil Jorgensen from Gentofte Hospital in Hellerup said by email. "It supports our concern that in a low-risk population, beta-blocker-associated risks may outweigh the advantages of the treatment, in a wide range of low-risk patients."

Several studies have shown that perioperative beta-blocker use may benefit patients at high cardiac risk, but may increase mortality in others. Guidelines from the United States and Europe support continuing beta-blocker use perioperatively in patients already using being treated with them, but literature support for these recommendations is sparse.

Dr. Jorgensen's team used data from Statistics Denmark to investigate whether perioperative beta-blocker use is associated with an increased risk of major adverse cardiovascular events (MACEs) and all-cause mortality in the 30 days after noncardiac surgery in hypertensive patients free of cardiac, renal, and liver disease.

Among 14,644 patients treated with beta-blockers and 40,676 patients treated with other antihypertensives, the incidence of 30-day MACEs was significantly higher among those taking beta-blockers than among those taking other antihypertensives (1.32% vs. 0.84%, p<0.001).

Thirty-day all-cause mortality was also significantly higher in the beta-blocker group than in the other antihypertensives group (1.93% vs. 1.32%, p<0.001), the researchers report in JAMA Internal Medicine, online Oct. 5.

With the exception of combinations that included beta-blockers and two other antihypertensive drugs, all regimens that included a beta-blocker were associated with significantly increased risks of MACE and all-cause mortality, compared with regimens of renin-angiotensin system inhibitors and thiazides.

Results were comparable in subgroup analyses of diabetics versus nondiabetics and patients with low risk versus elevated risk.

The elevated risks were especially notable among patients at least 70 years old (number needed to harm, NNH, 140), men (NNH, 142), and patients undergoing acute surgery (NNH, 97).

"This study, among others, presents the case that the beneficial effects of beta-blockers might be subgroup dependent and that beta-blockers may not be the safe haven that previous perioperative guidelines have suggested," Dr. Jorgensen concluded. "More studies are needed to further the understanding of patient subgroups at risk, preferably in the setting of a randomized trial."

"The use of beta-blockers in 1 out of 4 patients with uncomplicated hypertension was higher than expected, as beta-blockers are no longer first-line drugs for treating hypertension," Dr. Jorgensen noted. "The high prevalence of beta-blocker use in this patient group underlines the clinical importance of these findings."

"Although we cannot conclude on whether the therapy should be changed prior to surgery, clinicians might want to pay special attention to these otherwise low-risk patients in the perioperative setting," he said.

"It is important to keep in mind that our population consisted of hypertensive patients without cardiac, renal or liver disease; thus not all patients with hypertension receiving a beta-blocker are expected to be at increased risk," Dr. Jorgensen cautioned. "Several conditions may necessitate and fully justify the use of beta-blockers, such as congestive heart failure or recent myocardial infarction, as demonstrated in a previous study from our research group."

Dr. Mark L. Friedell from the University of Missouri Kansas City School of Medicine in Kansas City coauthored one of the earlier reports that called into question the safety of perioperative beta-blocker use in low-risk patients. He said by email, "I was surprised at the higher mortality of patients with no cardiac risk factors. But, when taking the POISE trial into consideration, it makes sense that patients with no risk factors might be the ones most harmed by hypotension/stroke since there was no counter balance of cardiac protection such as that given to the patients with 3-4 cardiac risk factors."

His conclusion: "Patients with no or 1-2 cardiac risk factors do not need to be started on a beta-blocker perioperatively to try to mitigate cardiac risk."

"I think patients with perioperative hypertension and tachycardia could probably still be treated with short-acting beta-blockers," Dr. Friedell said. "If starting a beta-blocker in preparation for surgery (3-4 cardiac risk factors), do it at least a week in advance."

Dr. Elisabetta Patorno from Harvard Medical School in Boston recently coauthored a report of patterns of beta-blocker initiation in patients undergoing noncardiac surgery.

"These findings are just one piece of information and it is important not to overreact to only one study," she cautioned in an email. "These findings should be considered in addition to other available research, recommendations from professional societies like the American Heart Association, and patient specific considerations, when deciding regarding the perioperative management of patients with hypertension."

"Doctors should also balance these findings in light of the possible problems associated with this study," Dr. Patorno said. "Beta-blockers are not typically a first-line treatment for hypertension, so it is conceivable that the study participants treated with beta-blockers may have had a longer history and greater severity of hypertension compared with the patients treated with other antihypertensive therapy (the comparison group used in this study). This suggests the groups may be inherently different, with the implication that the underlying differential severity of hypertension and not the specific treatment may be responsible for the post-surgical increased risk of cardiovascular events and mortality observed among patients treated with beta-blocker therapy."

"Finally," she said, "as this study focuses on chronic antihypertensive users only, the question of whether there is real benefit or harm associated with initiating beta-blocker therapy prior to surgery remains unanswered."

Dr. Hermann Blessberger from Johannes Kepler University Linz School of Medicine, Linz, Austria, who has coauthored several papers regarding perioperative beta-blocker use, offered similar comments.

"We learned from our meta-analysis that dosage of beta-blockers (heart rate titrated), time point of start of beta-blockers before surgery (at least 2 weeks prior to surgery to allow the circulatory system to accommodate) as well as type of beta-blocker (issue with metoprolol metabolism - blood level may be heavily increased in poor metabolizers) are crucial," he said. "Except for the type of beta-blocker (mainly metoprolol and atenolol) this information could not be provided in this article as we can read in the discussion section but may be important."

"If a patient suffers from arterial hypertension, do not use a beta-blocker for initial treatment unless a beta-blocker seems desirable for another condition (rhythm disturbances, coronary heart disease, hyperthyroidism, etc.)," he advised.

NEW YORK - Perioperative beta-blocker use in patients with hypertension is associated with increased cardiovascular complications and mortality after noncardiac surgery, researchers from Denmark report.

"The consistency of the findings of increased risks associated with beta-blockers across numerous subgroups was an important finding," Dr. Mads Emil Jorgensen from Gentofte Hospital in Hellerup said by email. "It supports our concern that in a low-risk population, beta-blocker-associated risks may outweigh the advantages of the treatment, in a wide range of low-risk patients."

Several studies have shown that perioperative beta-blocker use may benefit patients at high cardiac risk, but may increase mortality in others. Guidelines from the United States and Europe support continuing beta-blocker use perioperatively in patients already using being treated with them, but literature support for these recommendations is sparse.

Dr. Jorgensen's team used data from Statistics Denmark to investigate whether perioperative beta-blocker use is associated with an increased risk of major adverse cardiovascular events (MACEs) and all-cause mortality in the 30 days after noncardiac surgery in hypertensive patients free of cardiac, renal, and liver disease.

Among 14,644 patients treated with beta-blockers and 40,676 patients treated with other antihypertensives, the incidence of 30-day MACEs was significantly higher among those taking beta-blockers than among those taking other antihypertensives (1.32% vs. 0.84%, p<0.001).

Thirty-day all-cause mortality was also significantly higher in the beta-blocker group than in the other antihypertensives group (1.93% vs. 1.32%, p<0.001), the researchers report in JAMA Internal Medicine, online Oct. 5.

With the exception of combinations that included beta-blockers and two other antihypertensive drugs, all regimens that included a beta-blocker were associated with significantly increased risks of MACE and all-cause mortality, compared with regimens of renin-angiotensin system inhibitors and thiazides.

Results were comparable in subgroup analyses of diabetics versus nondiabetics and patients with low risk versus elevated risk.

The elevated risks were especially notable among patients at least 70 years old (number needed to harm, NNH, 140), men (NNH, 142), and patients undergoing acute surgery (NNH, 97).

"This study, among others, presents the case that the beneficial effects of beta-blockers might be subgroup dependent and that beta-blockers may not be the safe haven that previous perioperative guidelines have suggested," Dr. Jorgensen concluded. "More studies are needed to further the understanding of patient subgroups at risk, preferably in the setting of a randomized trial."

"The use of beta-blockers in 1 out of 4 patients with uncomplicated hypertension was higher than expected, as beta-blockers are no longer first-line drugs for treating hypertension," Dr. Jorgensen noted. "The high prevalence of beta-blocker use in this patient group underlines the clinical importance of these findings."

"Although we cannot conclude on whether the therapy should be changed prior to surgery, clinicians might want to pay special attention to these otherwise low-risk patients in the perioperative setting," he said.

"It is important to keep in mind that our population consisted of hypertensive patients without cardiac, renal or liver disease; thus not all patients with hypertension receiving a beta-blocker are expected to be at increased risk," Dr. Jorgensen cautioned. "Several conditions may necessitate and fully justify the use of beta-blockers, such as congestive heart failure or recent myocardial infarction, as demonstrated in a previous study from our research group."

Dr. Mark L. Friedell from the University of Missouri Kansas City School of Medicine in Kansas City coauthored one of the earlier reports that called into question the safety of perioperative beta-blocker use in low-risk patients. He said by email, "I was surprised at the higher mortality of patients with no cardiac risk factors. But, when taking the POISE trial into consideration, it makes sense that patients with no risk factors might be the ones most harmed by hypotension/stroke since there was no counter balance of cardiac protection such as that given to the patients with 3-4 cardiac risk factors."

His conclusion: "Patients with no or 1-2 cardiac risk factors do not need to be started on a beta-blocker perioperatively to try to mitigate cardiac risk."

"I think patients with perioperative hypertension and tachycardia could probably still be treated with short-acting beta-blockers," Dr. Friedell said. "If starting a beta-blocker in preparation for surgery (3-4 cardiac risk factors), do it at least a week in advance."

Dr. Elisabetta Patorno from Harvard Medical School in Boston recently coauthored a report of patterns of beta-blocker initiation in patients undergoing noncardiac surgery.

"These findings are just one piece of information and it is important not to overreact to only one study," she cautioned in an email. "These findings should be considered in addition to other available research, recommendations from professional societies like the American Heart Association, and patient specific considerations, when deciding regarding the perioperative management of patients with hypertension."

"Doctors should also balance these findings in light of the possible problems associated with this study," Dr. Patorno said. "Beta-blockers are not typically a first-line treatment for hypertension, so it is conceivable that the study participants treated with beta-blockers may have had a longer history and greater severity of hypertension compared with the patients treated with other antihypertensive therapy (the comparison group used in this study). This suggests the groups may be inherently different, with the implication that the underlying differential severity of hypertension and not the specific treatment may be responsible for the post-surgical increased risk of cardiovascular events and mortality observed among patients treated with beta-blocker therapy."

"Finally," she said, "as this study focuses on chronic antihypertensive users only, the question of whether there is real benefit or harm associated with initiating beta-blocker therapy prior to surgery remains unanswered."

Dr. Hermann Blessberger from Johannes Kepler University Linz School of Medicine, Linz, Austria, who has coauthored several papers regarding perioperative beta-blocker use, offered similar comments.

"We learned from our meta-analysis that dosage of beta-blockers (heart rate titrated), time point of start of beta-blockers before surgery (at least 2 weeks prior to surgery to allow the circulatory system to accommodate) as well as type of beta-blocker (issue with metoprolol metabolism - blood level may be heavily increased in poor metabolizers) are crucial," he said. "Except for the type of beta-blocker (mainly metoprolol and atenolol) this information could not be provided in this article as we can read in the discussion section but may be important."

"If a patient suffers from arterial hypertension, do not use a beta-blocker for initial treatment unless a beta-blocker seems desirable for another condition (rhythm disturbances, coronary heart disease, hyperthyroidism, etc.)," he advised.

NEW YORK - Perioperative beta-blocker use in patients with hypertension is associated with increased cardiovascular complications and mortality after noncardiac surgery, researchers from Denmark report.

"The consistency of the findings of increased risks associated with beta-blockers across numerous subgroups was an important finding," Dr. Mads Emil Jorgensen from Gentofte Hospital in Hellerup said by email. "It supports our concern that in a low-risk population, beta-blocker-associated risks may outweigh the advantages of the treatment, in a wide range of low-risk patients."

Several studies have shown that perioperative beta-blocker use may benefit patients at high cardiac risk, but may increase mortality in others. Guidelines from the United States and Europe support continuing beta-blocker use perioperatively in patients already using being treated with them, but literature support for these recommendations is sparse.

Dr. Jorgensen's team used data from Statistics Denmark to investigate whether perioperative beta-blocker use is associated with an increased risk of major adverse cardiovascular events (MACEs) and all-cause mortality in the 30 days after noncardiac surgery in hypertensive patients free of cardiac, renal, and liver disease.

Among 14,644 patients treated with beta-blockers and 40,676 patients treated with other antihypertensives, the incidence of 30-day MACEs was significantly higher among those taking beta-blockers than among those taking other antihypertensives (1.32% vs. 0.84%, p<0.001).

Thirty-day all-cause mortality was also significantly higher in the beta-blocker group than in the other antihypertensives group (1.93% vs. 1.32%, p<0.001), the researchers report in JAMA Internal Medicine, online Oct. 5.

With the exception of combinations that included beta-blockers and two other antihypertensive drugs, all regimens that included a beta-blocker were associated with significantly increased risks of MACE and all-cause mortality, compared with regimens of renin-angiotensin system inhibitors and thiazides.

Results were comparable in subgroup analyses of diabetics versus nondiabetics and patients with low risk versus elevated risk.

The elevated risks were especially notable among patients at least 70 years old (number needed to harm, NNH, 140), men (NNH, 142), and patients undergoing acute surgery (NNH, 97).

"This study, among others, presents the case that the beneficial effects of beta-blockers might be subgroup dependent and that beta-blockers may not be the safe haven that previous perioperative guidelines have suggested," Dr. Jorgensen concluded. "More studies are needed to further the understanding of patient subgroups at risk, preferably in the setting of a randomized trial."

"The use of beta-blockers in 1 out of 4 patients with uncomplicated hypertension was higher than expected, as beta-blockers are no longer first-line drugs for treating hypertension," Dr. Jorgensen noted. "The high prevalence of beta-blocker use in this patient group underlines the clinical importance of these findings."

"Although we cannot conclude on whether the therapy should be changed prior to surgery, clinicians might want to pay special attention to these otherwise low-risk patients in the perioperative setting," he said.

"It is important to keep in mind that our population consisted of hypertensive patients without cardiac, renal or liver disease; thus not all patients with hypertension receiving a beta-blocker are expected to be at increased risk," Dr. Jorgensen cautioned. "Several conditions may necessitate and fully justify the use of beta-blockers, such as congestive heart failure or recent myocardial infarction, as demonstrated in a previous study from our research group."

Dr. Mark L. Friedell from the University of Missouri Kansas City School of Medicine in Kansas City coauthored one of the earlier reports that called into question the safety of perioperative beta-blocker use in low-risk patients. He said by email, "I was surprised at the higher mortality of patients with no cardiac risk factors. But, when taking the POISE trial into consideration, it makes sense that patients with no risk factors might be the ones most harmed by hypotension/stroke since there was no counter balance of cardiac protection such as that given to the patients with 3-4 cardiac risk factors."

His conclusion: "Patients with no or 1-2 cardiac risk factors do not need to be started on a beta-blocker perioperatively to try to mitigate cardiac risk."

"I think patients with perioperative hypertension and tachycardia could probably still be treated with short-acting beta-blockers," Dr. Friedell said. "If starting a beta-blocker in preparation for surgery (3-4 cardiac risk factors), do it at least a week in advance."

Dr. Elisabetta Patorno from Harvard Medical School in Boston recently coauthored a report of patterns of beta-blocker initiation in patients undergoing noncardiac surgery.

"These findings are just one piece of information and it is important not to overreact to only one study," she cautioned in an email. "These findings should be considered in addition to other available research, recommendations from professional societies like the American Heart Association, and patient specific considerations, when deciding regarding the perioperative management of patients with hypertension."

"Doctors should also balance these findings in light of the possible problems associated with this study," Dr. Patorno said. "Beta-blockers are not typically a first-line treatment for hypertension, so it is conceivable that the study participants treated with beta-blockers may have had a longer history and greater severity of hypertension compared with the patients treated with other antihypertensive therapy (the comparison group used in this study). This suggests the groups may be inherently different, with the implication that the underlying differential severity of hypertension and not the specific treatment may be responsible for the post-surgical increased risk of cardiovascular events and mortality observed among patients treated with beta-blocker therapy."

"Finally," she said, "as this study focuses on chronic antihypertensive users only, the question of whether there is real benefit or harm associated with initiating beta-blocker therapy prior to surgery remains unanswered."

Dr. Hermann Blessberger from Johannes Kepler University Linz School of Medicine, Linz, Austria, who has coauthored several papers regarding perioperative beta-blocker use, offered similar comments.

"We learned from our meta-analysis that dosage of beta-blockers (heart rate titrated), time point of start of beta-blockers before surgery (at least 2 weeks prior to surgery to allow the circulatory system to accommodate) as well as type of beta-blocker (issue with metoprolol metabolism - blood level may be heavily increased in poor metabolizers) are crucial," he said. "Except for the type of beta-blocker (mainly metoprolol and atenolol) this information could not be provided in this article as we can read in the discussion section but may be important."

"If a patient suffers from arterial hypertension, do not use a beta-blocker for initial treatment unless a beta-blocker seems desirable for another condition (rhythm disturbances, coronary heart disease, hyperthyroidism, etc.)," he advised.

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK - Most, but not all, guideline-recommended drugs and their combinations yield modest survival benefits in older adults with multiple chronic medical conditions, researchers report.

"Until there is better evidence in older adults with multiple chronic conditions, clinicians need to take a more thoughtful and nuanced approach to medication prescribing," Dr. Mary E. Tinetti from Yale School of Medicine, New Haven, Connecticut said by email. "This is particularly supported by the fact that outside of perhaps anticoagulation for atrial fibrillation, the magnitude of benefit for most of these medications is quite modest."

Nearly 40% of adults 65 years and older take at least five prescription medications, but the benefits of drugs prescribed for a single condition are difficult to ascertain in the

presence of multiple conditions and drugs.

Dr. Tinetti and colleagues used data from the Medicare Current Beneficiary Survey to estimate the association between nine guideline-recommended and commonly prescribed drugs and death in more than 8,500 Medicare participants (mean age, 77.4 years).

The nine drugs included beta-blockers; calcium channel blockers; clopidogrel; metformin; renin-angiotensin system (RAS) blockers; selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs); statins; thiazide diuretics; and warfarin.

The most common medical conditions included hypertension, hyperlipidemia, diabetes, and coronary artery disease, the researchers report in The BMJ, online Oct. 2. More than half of the participants took at least three of the nine study drugs, and the mean number of total drugs was 10.0.

The benefits on survival of beta-blockers, calcium channel blockers, RAS blockers, statins, and warfarin were comparable to those reported in randomized controlled trials, although for beta-blockers and warfarin they varied according to coexisting conditions.

Clopidogrel, metformin, and SSRIs/SNRIs, however, were not associated with survival benefits.

The association between drug use and mortality risk was generally similar across patterns of coexisting conditions, suggesting to the researchers "that benefits often remain despite comorbidity."

"Research focused on identifying the medications that have the greatest benefit (defined by patient's outcomes priority such as improved symptoms, optimal physical or cognitive function, or survival) and least harm for key subpopulations of individuals with varying combinations of coexisting conditions should be a top priority," Dr. Tinetti said. "Ironically, although these are the major users of health care, they have largely been ignored in research."

"Many individuals, although they have many conditions, only one or two are really affecting the outcomes that matter most to them," Dr. Tinetti said. "Therefore, medication regimens can be simplified by eliminating medications for conditions that are not likely to benefit the individuals outcome priority, such as improved symptoms, optimal physical or cognitive function, or simplified treatment regimens."

"We know that about one in five individuals are currently receiving guideline-recommended medications for one condition that may be harming another," Dr. Tinetti concluded. "A careful medication review will review these potential offending medications. Given the marginal benefit of each individual medication, and the importance of avoiding harm, potentially offending medications should be discontinued."

Dr. Una Makris from UT Southwestern Medical Center and Dallas VA Medical Center has reported on high-risk medication use among older veterans with chronic pain. She said by email, "As clinicians we need to understand that not all of the outcomes we measure and not all of the medical conditions a patient has will be perceived as equally important (by the patient), so involving patients in the decision of which medications (even if guideline concordant) to add or remove is integral. How we communicate with and educate our older patients about their chronic conditions and the risks/benefits of each medication is evolving; this often differs between specialty providers and primary care providers."

Dr. Makris added, "This publication should heighten our awareness that patients, especially older adults, often have multiple comorbidities that can be treated with multiple guideline driven therapies and that our goal is really to work with patients to determine which combination of drugs and for which condition optimizes the risks/benefits for that individual."

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

NEW YORK  - The five-factor ORBIT bleeding score accurately predicts major bleeding risk in patients with atrial fibrillation (AF) who are taking oral anticoagulants (OACs), researchers report.

"The ORBIT score highlights modifiable factors that increase bleeding risk and can help providers identify high-risk AF patients for closer monitoring," Dr. Emily C. O'Brien, from Duke Clinical Research Institute, Durham, North Carolina, said by email. "Along with clinical judgment, the ORBIT score can be used to give an estimate of bleeding risk for any AF patient considering OAC treatment."

Two existing bleeding scores - HAS-BLED and ATRIA - are based on small numbers of events and have shown inconsistent performance. They also may require elements that are not available for all OAC users, the researchers wrote.

Dr. O'Brien's team developed a five-element bleeding score and compared its performance with those of HAS-BLED and ATRIA using data from the ORBIT-AF and ROCKET-AF studies.

The numerical score included the five strongest predictors of bleeding:

-Older age (75 years and above): one point

-Reduced hemoglobin, hematocrit, or history of anemia: two points

-Bleeding history: two points

-Insufficient kidney function (eGFR below 60 mL/min/1.73 m2): one point

-Treatment with an antiplatelet agent: one point

Observed bleeding rates in the ORBIT-AF participants increased with increasing ORBIT bleeding score: from 2.4 per 100 patient-years in the low-risk group (scores 0-2) to 4.7 per 100 patient-years in the medium-risk group (score 3) to 8.1 per 100 patient-years in the high-risk group (scores 4-7), according to the Sept. 30 European Heart Journal online report.

In both the ORBIT-AF and ROCKET-AF cohorts, the ORBIT bleeding score showed better discrimination than the HAS-BLED and ATRIA scores.

Model calibration analysis also showed superior calibration for the ORBIT bleeding score. The HAS-BLED score showed relatively poor calibration for low-risk score strata, whereas the ATRIA score showed poor calibration for most risk groups.

"The ORBIT score is a simple, useful tool that predicts bleeding as well as other, more complicated scores and can be used in any AF patient regardless of the type of OAC he or she is taking," Dr. O'Brien said.

"For chronic conditions like AF, periodic assessment of risk for adverse events is important to support clinical decision-making," Dr. O'Brien explained. "Risk factors may

change over time particularly as patients get older. Therefore, incorporating new data on these factors into longitudinal risk assessment provides an optimal framework for ongoing AF management."

"While bleeding risk estimation can be helpful in identifying high-risk AF patients for closer monitoring, it is important to note that prior work has demonstrated a net clinical benefit of OAC even in patients with high estimated bleeding risk," the researchers wrote. "Further, while risk scores provide important information to the clinician for estimating risk of adverse events, they represent only one consideration relevant to therapeutic decision making."

Janssen Scientific Affairs sponsors ORBIT-AF; the Agency for Healthcare Research and Quality partially supported this research. Ten coauthors reported relevant relationships.

NEW YORK - A variant of the CHADS2 score that's used to estimate ischemic stroke risk in patients with atrial fibrillation (AF) is also modestly accurate in heart failure patients, even in those without AF, researchers say. The variant, CHA2DS2-VASc, calculates stroke risk based on 10 possible points with higher scores indicating higher risk.

Line Melgaard from Aalborg University in Denmark and colleagues used three Danish nationwide registries to investigate whether the CHA2DS2-VASc score could predict ischemic stroke, thromboembolism, and death in patients with heart failure without AF as effectively as it does in patients with AF.

Patients with heart failure had a high risk of all three outcomes, whether or not AF was present, and the CHA2DS2-VASc score modestly predicted these endpoints at one-year and five-year follow-up (C statistics, 0.67 and 0.69, respectively).

Heart failure patients without AF whose CHA2DS2-VASc score was 4 or higher had increased risks of ischemic stroke, thromboembolism, and death in a manner comparable to patients with AF, according to the August 30 JAMA online report.

The negative predictive value (NPV) was around 90% at one-year follow-up for all three outcomes, although NPVs were strongly attenuated by the five-year follow-up.

"In our study, one of our principal findings was that the absolute risk of ischemic stroke among patients without AF was about 1.5% per year or higher with CHA2DS2-VASc scores of 2 or higher, with associated five-year absolute ischemic stroke risks in excess of 4% or more," the researchers noted. This risk level would be sufficient to prompt initiation of long-term anticoagulation in patients with AF, they say.

"The poor prognosis of atrial fibrillation for ischemic stroke and death in patients with heart failure was evident in our study and expected," Melgaard said. "But the observation that additional risk factors in patients with heart failure are particularly significant among those without atrial fibrillation is an important and (to some extent) unexpected result."

"I hope physicians will recognize that patients with heart failure and sinus rhythm have an increased risk of ischemic stroke, and that some subgroups within this population most likely need thromboprophylaxis," Melgaard concluded. "Especially patients with multiple comorbidities (high CHA2DS2-VASc score) need attention in the clinic."

NEW YORK - A variant of the CHADS2 score that's used to estimate ischemic stroke risk in patients with atrial fibrillation (AF) is also modestly accurate in heart failure patients, even in those without AF, researchers say. The variant, CHA2DS2-VASc, calculates stroke risk based on 10 possible points with higher scores indicating higher risk.

Line Melgaard from Aalborg University in Denmark and colleagues used three Danish nationwide registries to investigate whether the CHA2DS2-VASc score could predict ischemic stroke, thromboembolism, and death in patients with heart failure without AF as effectively as it does in patients with AF.

Patients with heart failure had a high risk of all three outcomes, whether or not AF was present, and the CHA2DS2-VASc score modestly predicted these endpoints at one-year and five-year follow-up (C statistics, 0.67 and 0.69, respectively).

Heart failure patients without AF whose CHA2DS2-VASc score was 4 or higher had increased risks of ischemic stroke, thromboembolism, and death in a manner comparable to patients with AF, according to the August 30 JAMA online report.

The negative predictive value (NPV) was around 90% at one-year follow-up for all three outcomes, although NPVs were strongly attenuated by the five-year follow-up.

"In our study, one of our principal findings was that the absolute risk of ischemic stroke among patients without AF was about 1.5% per year or higher with CHA2DS2-VASc scores of 2 or higher, with associated five-year absolute ischemic stroke risks in excess of 4% or more," the researchers noted. This risk level would be sufficient to prompt initiation of long-term anticoagulation in patients with AF, they say.

"The poor prognosis of atrial fibrillation for ischemic stroke and death in patients with heart failure was evident in our study and expected," Melgaard said. "But the observation that additional risk factors in patients with heart failure are particularly significant among those without atrial fibrillation is an important and (to some extent) unexpected result."

"I hope physicians will recognize that patients with heart failure and sinus rhythm have an increased risk of ischemic stroke, and that some subgroups within this population most likely need thromboprophylaxis," Melgaard concluded. "Especially patients with multiple comorbidities (high CHA2DS2-VASc score) need attention in the clinic."

NEW YORK - A variant of the CHADS2 score that's used to estimate ischemic stroke risk in patients with atrial fibrillation (AF) is also modestly accurate in heart failure patients, even in those without AF, researchers say. The variant, CHA2DS2-VASc, calculates stroke risk based on 10 possible points with higher scores indicating higher risk.

Line Melgaard from Aalborg University in Denmark and colleagues used three Danish nationwide registries to investigate whether the CHA2DS2-VASc score could predict ischemic stroke, thromboembolism, and death in patients with heart failure without AF as effectively as it does in patients with AF.

Patients with heart failure had a high risk of all three outcomes, whether or not AF was present, and the CHA2DS2-VASc score modestly predicted these endpoints at one-year and five-year follow-up (C statistics, 0.67 and 0.69, respectively).

Heart failure patients without AF whose CHA2DS2-VASc score was 4 or higher had increased risks of ischemic stroke, thromboembolism, and death in a manner comparable to patients with AF, according to the August 30 JAMA online report.

The negative predictive value (NPV) was around 90% at one-year follow-up for all three outcomes, although NPVs were strongly attenuated by the five-year follow-up.

"In our study, one of our principal findings was that the absolute risk of ischemic stroke among patients without AF was about 1.5% per year or higher with CHA2DS2-VASc scores of 2 or higher, with associated five-year absolute ischemic stroke risks in excess of 4% or more," the researchers noted. This risk level would be sufficient to prompt initiation of long-term anticoagulation in patients with AF, they say.

"The poor prognosis of atrial fibrillation for ischemic stroke and death in patients with heart failure was evident in our study and expected," Melgaard said. "But the observation that additional risk factors in patients with heart failure are particularly significant among those without atrial fibrillation is an important and (to some extent) unexpected result."

"I hope physicians will recognize that patients with heart failure and sinus rhythm have an increased risk of ischemic stroke, and that some subgroups within this population most likely need thromboprophylaxis," Melgaard concluded. "Especially patients with multiple comorbidities (high CHA2DS2-VASc score) need attention in the clinic."

NEW YORK - The American College of Physicians (ACP) has issued a baker's dozen of recommendations intended to guide the effective use of telemedicine in primary care settings.

"The recommendations balance the potential benefits and expanded use of telemedicine with the importance of maintaining the patient-physician relationship and patient safety," Hilary Daniel from American College of Physicians, Washington, DC, said by email.

Telemedicine, the use of technology to deliver health care services at a distance, began mainly in rural communities and federal health programs, but now is used in a variety of medical specialties and subspecialties.

Daniel and colleagues on the ACP Health and Public Policy Committee detail pragmatic recommendations on the use of telemedicine in the primary care setting, physician considerations for those who use telemedicine in their practices, and policy recommendations on the practice and reimbursement of telemedicine in their September 8 Annals of Internal Medicine online position paper.

While ACP "supports the expanded role of telemedicine as a method of health care delivery that may enhance patient-physician collaborations," it also recommends that direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient's primary care physician when necessary to meet the patient's immediate care

needs.

These services should take place within the context of a valid patient-physician relationship. Physicians who use telemedicine have an obligation to establish such a relationship based on the standard of care required for an in-person visit or consult with another physician who has such a relationship with the patient.

Physicians should take care to see that financially disadvantaged populations also have access to telemedicine services, where appropriate, as well as ensure that these services comply with federal and state security and privacy regulations while meeting the same standards of practice as if the physician were seeing the patient in person.

ACP supports efforts to reimburse telemedicine communications and telehealth services and supports processes to obtain medical licenses and hospital privileges necessary to support telemedicine across state lines.

The committee also endorses the use of federal funds to support the broadband infrastructure and to establish an evidence base on the safety, efficacy, and cost of telemedicine technologies.

"Telemedicine can be an effective and beneficial tool for physicians and patients to enhance a patient's care," Daniel concluded. "Physicians can take away from this report a greater understanding of the regulatory and payment issues surrounding telemedicine and evaluate how telemedicine may be useful for their patients and practice and augment the care they already provide."

In a related editorial, Dr. David A. Asch, from the University of Pennsylvania's Center for Health Care Innovation, Philadelphia, addressed the hidden economics of telemedicine. He said by email, "I think it is a trap to think that the only promise of telemedicine is the opportunity to do something remotely that used to happen face to face. The real opportunities will come from doing health care in a different way because of this remote technology."

"An important question is, 'If there are so many opportunities from telemedicine, why doesn't more of it happen?'" Dr. Asch said. "I think there are a lot of reasons for that but one important reason is that insurers, in particular, worry that if they make telemedicine payments easy, then they will open up the floodgates of demand."

Dr. Laura Markwick, from Wegmans School of Nursing, St. John Fisher College, Rochester, New York, said by email, "I would like to apply these to all health care providers and not just physicians. Of note, they do mention that they recommend a relationship already be established with the patient, which I do not feel is an absolute must. When we did our telemedicine program, we did not have a previous in-person relationship established and we were able to provide high-quality care that improved access for the patients."

"All health care providers should be reimbursed for telemedicine care, at levels similar to what is reimbursed currently," Dr. Markwick said. "This should be a covered service from the person's insurance, depending upon the care needed. If it is just someone who does not feel like making it to an appointment but otherwise could with little difficulty (social issues included in this decision), then perhaps the patient should contribute toward this reimbursement."

Dr. Manish N. Shah, from the University of Wisconsin School of Medicine and Public Health, Madison, said by email, "It is important to know that the U.S. is behind the rest of the world when it comes to telemedicine. In Canada, the Ontario Telemedicine Network has existed for years. In the UK, telemedicine has been also available."

"Reimbursement for telemedicine is a complex issue, particularly because the entire provider payment system is changing," Dr. Shah said. "However, without funding, telemedicine will not be made available to patients despite increasing evidence showing that patients want to use it, that care can be effectively delivered via telemedicine, and that telemedicine is cost effective."

The authors reported no external funding or disclosures.

NEW YORK - The American College of Physicians (ACP) has issued a baker's dozen of recommendations intended to guide the effective use of telemedicine in primary care settings.

"The recommendations balance the potential benefits and expanded use of telemedicine with the importance of maintaining the patient-physician relationship and patient safety," Hilary Daniel from American College of Physicians, Washington, DC, said by email.

Telemedicine, the use of technology to deliver health care services at a distance, began mainly in rural communities and federal health programs, but now is used in a variety of medical specialties and subspecialties.

Daniel and colleagues on the ACP Health and Public Policy Committee detail pragmatic recommendations on the use of telemedicine in the primary care setting, physician considerations for those who use telemedicine in their practices, and policy recommendations on the practice and reimbursement of telemedicine in their September 8 Annals of Internal Medicine online position paper.

While ACP "supports the expanded role of telemedicine as a method of health care delivery that may enhance patient-physician collaborations," it also recommends that direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient's primary care physician when necessary to meet the patient's immediate care

needs.

These services should take place within the context of a valid patient-physician relationship. Physicians who use telemedicine have an obligation to establish such a relationship based on the standard of care required for an in-person visit or consult with another physician who has such a relationship with the patient.

Physicians should take care to see that financially disadvantaged populations also have access to telemedicine services, where appropriate, as well as ensure that these services comply with federal and state security and privacy regulations while meeting the same standards of practice as if the physician were seeing the patient in person.

ACP supports efforts to reimburse telemedicine communications and telehealth services and supports processes to obtain medical licenses and hospital privileges necessary to support telemedicine across state lines.

The committee also endorses the use of federal funds to support the broadband infrastructure and to establish an evidence base on the safety, efficacy, and cost of telemedicine technologies.

"Telemedicine can be an effective and beneficial tool for physicians and patients to enhance a patient's care," Daniel concluded. "Physicians can take away from this report a greater understanding of the regulatory and payment issues surrounding telemedicine and evaluate how telemedicine may be useful for their patients and practice and augment the care they already provide."

In a related editorial, Dr. David A. Asch, from the University of Pennsylvania's Center for Health Care Innovation, Philadelphia, addressed the hidden economics of telemedicine. He said by email, "I think it is a trap to think that the only promise of telemedicine is the opportunity to do something remotely that used to happen face to face. The real opportunities will come from doing health care in a different way because of this remote technology."

"An important question is, 'If there are so many opportunities from telemedicine, why doesn't more of it happen?'" Dr. Asch said. "I think there are a lot of reasons for that but one important reason is that insurers, in particular, worry that if they make telemedicine payments easy, then they will open up the floodgates of demand."

Dr. Laura Markwick, from Wegmans School of Nursing, St. John Fisher College, Rochester, New York, said by email, "I would like to apply these to all health care providers and not just physicians. Of note, they do mention that they recommend a relationship already be established with the patient, which I do not feel is an absolute must. When we did our telemedicine program, we did not have a previous in-person relationship established and we were able to provide high-quality care that improved access for the patients."

"All health care providers should be reimbursed for telemedicine care, at levels similar to what is reimbursed currently," Dr. Markwick said. "This should be a covered service from the person's insurance, depending upon the care needed. If it is just someone who does not feel like making it to an appointment but otherwise could with little difficulty (social issues included in this decision), then perhaps the patient should contribute toward this reimbursement."

Dr. Manish N. Shah, from the University of Wisconsin School of Medicine and Public Health, Madison, said by email, "It is important to know that the U.S. is behind the rest of the world when it comes to telemedicine. In Canada, the Ontario Telemedicine Network has existed for years. In the UK, telemedicine has been also available."

"Reimbursement for telemedicine is a complex issue, particularly because the entire provider payment system is changing," Dr. Shah said. "However, without funding, telemedicine will not be made available to patients despite increasing evidence showing that patients want to use it, that care can be effectively delivered via telemedicine, and that telemedicine is cost effective."

The authors reported no external funding or disclosures.

NEW YORK - The American College of Physicians (ACP) has issued a baker's dozen of recommendations intended to guide the effective use of telemedicine in primary care settings.

"The recommendations balance the potential benefits and expanded use of telemedicine with the importance of maintaining the patient-physician relationship and patient safety," Hilary Daniel from American College of Physicians, Washington, DC, said by email.

Telemedicine, the use of technology to deliver health care services at a distance, began mainly in rural communities and federal health programs, but now is used in a variety of medical specialties and subspecialties.

Daniel and colleagues on the ACP Health and Public Policy Committee detail pragmatic recommendations on the use of telemedicine in the primary care setting, physician considerations for those who use telemedicine in their practices, and policy recommendations on the practice and reimbursement of telemedicine in their September 8 Annals of Internal Medicine online position paper.

While ACP "supports the expanded role of telemedicine as a method of health care delivery that may enhance patient-physician collaborations," it also recommends that direct-to-patient telemedicine services should be used only as an intermittent alternative to a patient's primary care physician when necessary to meet the patient's immediate care

needs.

These services should take place within the context of a valid patient-physician relationship. Physicians who use telemedicine have an obligation to establish such a relationship based on the standard of care required for an in-person visit or consult with another physician who has such a relationship with the patient.

Physicians should take care to see that financially disadvantaged populations also have access to telemedicine services, where appropriate, as well as ensure that these services comply with federal and state security and privacy regulations while meeting the same standards of practice as if the physician were seeing the patient in person.

ACP supports efforts to reimburse telemedicine communications and telehealth services and supports processes to obtain medical licenses and hospital privileges necessary to support telemedicine across state lines.

The committee also endorses the use of federal funds to support the broadband infrastructure and to establish an evidence base on the safety, efficacy, and cost of telemedicine technologies.

"Telemedicine can be an effective and beneficial tool for physicians and patients to enhance a patient's care," Daniel concluded. "Physicians can take away from this report a greater understanding of the regulatory and payment issues surrounding telemedicine and evaluate how telemedicine may be useful for their patients and practice and augment the care they already provide."

In a related editorial, Dr. David A. Asch, from the University of Pennsylvania's Center for Health Care Innovation, Philadelphia, addressed the hidden economics of telemedicine. He said by email, "I think it is a trap to think that the only promise of telemedicine is the opportunity to do something remotely that used to happen face to face. The real opportunities will come from doing health care in a different way because of this remote technology."

"An important question is, 'If there are so many opportunities from telemedicine, why doesn't more of it happen?'" Dr. Asch said. "I think there are a lot of reasons for that but one important reason is that insurers, in particular, worry that if they make telemedicine payments easy, then they will open up the floodgates of demand."

Dr. Laura Markwick, from Wegmans School of Nursing, St. John Fisher College, Rochester, New York, said by email, "I would like to apply these to all health care providers and not just physicians. Of note, they do mention that they recommend a relationship already be established with the patient, which I do not feel is an absolute must. When we did our telemedicine program, we did not have a previous in-person relationship established and we were able to provide high-quality care that improved access for the patients."

"All health care providers should be reimbursed for telemedicine care, at levels similar to what is reimbursed currently," Dr. Markwick said. "This should be a covered service from the person's insurance, depending upon the care needed. If it is just someone who does not feel like making it to an appointment but otherwise could with little difficulty (social issues included in this decision), then perhaps the patient should contribute toward this reimbursement."

Dr. Manish N. Shah, from the University of Wisconsin School of Medicine and Public Health, Madison, said by email, "It is important to know that the U.S. is behind the rest of the world when it comes to telemedicine. In Canada, the Ontario Telemedicine Network has existed for years. In the UK, telemedicine has been also available."

"Reimbursement for telemedicine is a complex issue, particularly because the entire provider payment system is changing," Dr. Shah said. "However, without funding, telemedicine will not be made available to patients despite increasing evidence showing that patients want to use it, that care can be effectively delivered via telemedicine, and that telemedicine is cost effective."

The authors reported no external funding or disclosures.