Damian McNamara

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. “Laying on of hands lets the patients know that you care.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Absorbable sutures when indicated. “Patients who travel a great distance really appreciate not having to return for suture removal,” he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” Dr. Ceilley said.

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPPA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office.

“We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said. He suggested limiting the number of different suture types in the office. “For the rare cases where you need a different suture, keep them in a separate bin,” he said.

Arrange the surgical tray in a standard fashion. “We color-code instruments by room. This saves us time after autoclaving,” Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. “We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive.”

Trim and place dressings carefully, Dr. Ceilley said. “Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed.”

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. “Laying on of hands lets the patients know that you care.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Absorbable sutures when indicated. “Patients who travel a great distance really appreciate not having to return for suture removal,” he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” Dr. Ceilley said.

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPPA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office.

“We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said. He suggested limiting the number of different suture types in the office. “For the rare cases where you need a different suture, keep them in a separate bin,” he said.

Arrange the surgical tray in a standard fashion. “We color-code instruments by room. This saves us time after autoclaving,” Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. “We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive.”

Trim and place dressings carefully, Dr. Ceilley said. “Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed.”

ORLANDO — Optimize patient interaction, staff training, professional relationships, and office setup to increase office efficiency and personal satisfaction, Roger I. Ceilley, M.D., said in a presentation at the annual meeting of the Florida Society of Dermatologic Surgeons.

“Patient satisfaction plus personal satisfaction equals fun. And I'm having more fun in my practice now than I ever had,” said Dr. Ceilley of the department of dermatology at the University of Iowa, Iowa City.

Ask patients about their personal lives on the basis of a few words written in the record, look directly at patients when you speak—“some older patients have a component of lip reading”—and sit down with patients whenever possible, Dr. Ceilley suggested. Have a warm handshake and touch patients reassuringly, he added. “Laying on of hands lets the patients know that you care.”

Always review the chart before entering the room. It is okay to enter a room quickly, but always leave slowly, Dr. Ceilley said. “Look at the patient before you leave. Ask: 'Is there anything else you need?'”

Other factors that increase patient satisfaction include:

▸ Patient registration forms available on the practice's Web site, so patients can fill them out ahead of time if they desire.

▸ Dedicated check-in and check-out areas.

▸ Absorbable sutures when indicated. “Patients who travel a great distance really appreciate not having to return for suture removal,” he said.

▸ Good handouts and oral and written postoperative instructions. Advice on acceptable postoperative activities is critical. Emphasize the use of ice packs at home after surgery, Dr. Ceilley said. He suggested that patients use bags of frozen vegetables from their freezer.

▸ Free medication samples, and a prescription with enough refills to last until the next office visit.

▸ A sense of humor. “Humor is very important,” Dr. Ceilley said.

In addition, patients appreciate receiving letters ahead of time outlining a surgery or procedure. Physicians must give patients realistic expectations.

Always make a follow-up call to ascertain how patients are faring after an in-office procedure, he added.

When it comes to office assistants, it is critically important to train your own staff, Dr. Ceilley said. “When I used to have someone else train them, I realized after a few years that I was doing things the way my staff wanted, not the way I wanted.” He added that there are only two criteria for good office employees—intelligence and a positive attitude.

Another tip is to develop a close relationship with other physicians in the community. “That way, you don't call them only when you are in trouble,” Dr. Ceilley said.

He offered a wide range of practical tips for improving office setup. For example, a communication center separate from a patient reception area does not take front desk people away from the patients to answer the telephone. It is also a good way to meet the privacy requirements of the Health Insurance Portability and Accountability Act (HIPPA).

The communication center staff can make appointments and referrals, and recall patients. Dr. Ceilley has a dedicated pharmacy line in his communication center and encourages refills via fax. “The biggest waste of office time is medication refills and the time it takes to call in refills,” he said.

A sheet of preprinted labels in a patient chart can save time as well, Dr. Ceilley explained. Use a label maker to print out current patient information, including critical data, contact numbers, and insurance information, he suggested. “Just stick them on [documents] when needed, such as pathology requests.”

Track patients carefully; in his office, an oversized orange sheet is placed in the patient file. The sheet can be removed only by the physician. “That way, no one falls through the cracks.”

Standardization and organization are key to managing equipment in the office.

“We have each room in all three offices set up the same way for materials and supplies,” Dr. Ceilley said. He suggested limiting the number of different suture types in the office. “For the rare cases where you need a different suture, keep them in a separate bin,” he said.

Arrange the surgical tray in a standard fashion. “We color-code instruments by room. This saves us time after autoclaving,” Dr. Ceilley said. Consider a piece of sterile foam rubber for storing sharps before and after use, he added.

Keep a dressing tray in each room, he advised. “We use a lot of Micropore tape, which is just as effective as Steri-Strips, and a lot less expensive.”

Trim and place dressings carefully, Dr. Ceilley said. “Send patients home with a couple of days' worth of dressing material and information on where to buy more if needed.”

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders—18 million—and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science, Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast—in the first 24–48 hours—and the “effect is rather startling.”

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery. The surveys were supported by a grant from Forest Laboratories.

The surveys found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment adviser, for example.

When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

“The first thing we found in this survey is that alcoholism does not rate as high as our major issues of concern,” Mr. Rivlin said.

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders—18 million—and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science, Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast—in the first 24–48 hours—and the “effect is rather startling.”

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery. The surveys were supported by a grant from Forest Laboratories.

The surveys found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment adviser, for example.

When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

“The first thing we found in this survey is that alcoholism does not rate as high as our major issues of concern,” Mr. Rivlin said.

Primary care physicians are not very confident that medications to treat people with alcoholism will be effective: Only 26% of 300 general practitioners and internists taking an online survey thought medication would be effective or very effective.

The survey results also showed that many physicians do not address risk with patients. “Exactly half of doctors do not ask their patients about alcohol use,” Allan Rivlin said during a teleconference on alcoholism sponsored by the Community Anti-Drug Coalitions of America.

The 50% of physicians who inquire about alcohol consumption only do so half of the time or less. Reasons for this include a lack of resources (48%), patient denial (41%), and a belief that alcoholism is not their area of expertise (24%).

“The big clinical picture is there is a large population in this country with alcohol use disorders—18 million—and the majority never receive any help,” said David Kessler, M.D., dean of the school of medicine at the University of California, San Francisco, and former commissioner of the Food and Drug Administration.

Physicians can make a difference by asking patients directly about drinking. They can also help if they delay alcohol use in children and adolescents.

Primary care physicians who lack awareness and experience with medications for alcohol treatment are limiting patients' ability to recover, said Mr. Rivlin, senior vice president of Peter D. Hart Research Associates, the firm that conducted the online survey.

“People are preoccupied, anxious, overwhelmed, desperate. These medications give you a chance to bring them back into the fray,” said Drew Pinsky, M.D., medical director of the department of chemical dependency services at Las Encinas Hospital in Pasadena, Calif.

Despite the availability of medications, only 139,000 people in the United States are prescribed a drug to treat alcohol dependence or abuse, according to Alan Leshner, Ph.D., chief executive officer of the American Association for the Advancement of Science, Washington.

Just over half of physicians, 51%, reported prescribing disulfiram (Antabuse) at some point, and 26% said they currently prescribe the agent. A total of 26% have experience with naltrexone (Revia), and 15% have experience with the newest medication, acamprosate (Campral).

“Those who do have experience prescribing newer medications are much more likely to believe they are effective,” Mr. Rivlin said. For example, of physicians who have prescribed acamprosate, 45% believe it will lead to recovery, compared with 25% of nonprescribers.

“I use Campral a lot, almost exclusively at this point,” Dr. Pinsky said. Although it does not work in all patients, when it does work, it works fast—in the first 24–48 hours—and the “effect is rather startling.”

“I do not have a lot of use for Antabuse,” Dr. Pinsky said. “My patients, if they want to use, do not take their Antabuse.”

Most primary care physicians indicated that they refer patients with unhealthy drinking habits. Specifically, 49% refer such patients to a treatment facility, counselor, another doctor, or an addiction specialist. In addition, 20% refer to support groups. Only 13% recommend a combination of medication and counseling.

Attitudes and perceptions about alcoholism and its treatment were also gauged in similar online surveys of 1,000 members of the general public and 503 people in recovery. The surveys were supported by a grant from Forest Laboratories.

The surveys found that the general public might be more accepting of medications for alcohol treatment than would physicians. A total of 52% said they would be very likely to recommend that a family member try a medication if it was available and recommended by a doctor or treatment adviser, for example.

When asked if addiction to alcohol was primarily a disease/health problem, 56% of physicians agreed, 34% of the general public agreed, and 81% of people in recovery agreed. When asked if addiction to alcohol was primarily a personal/moral weakness, 9% of physicians agreed, 19% of the general public agreed, and 2% of people in recovery agreed. When asked if both play a role equally, 34% of physicians agreed, 44% of the general public agreed, and 9% of people in recovery agreed.

“The first thing we found in this survey is that alcoholism does not rate as high as our major issues of concern,” Mr. Rivlin said.

ORLANDO — Approximately half of limbs with varicose veins will have a skin complication, according to a retrospective study.

Venous disease affects an estimated 20% of women and 7% of men in the United States. Patients often present with one or more of these symptoms: aching, tiredness, heaviness in the legs, pain, cramping, swelling, itching, restless legs, and numbness, Ricardo Mejia, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Mejia and his colleague, Lawrence Tretbar, M.D., conducted a 10-month study of skin complications associated with venous disease. They assessed 113 limbs on 105 patients. Participants had surgery for incompetence of the great saphenous vein (102 limbs) or small saphenous vein (11 limbs). The age range was 23–83 years, and 78 of the participants were women. Approximately 50% of limbs (57 total) had skin findings, according to Dr. Mejia of Jupiter, Fla.

Men were 1.5 times more likely to present with dermatologic complications, although varicose veins are three times more common in women. Others at higher risk for skin manifestations include patients with advanced disease or of advanced age, and younger patients if they have a large saphenofemoral junction diameter (greater than 12 mm).

Clinical findings in the study included edema (32% of limbs), hyperpigmentation (24%), lipodermatosclerosis (13%), dermatitis (7%), atrophie blanche (4%), and lymphedema (1%).

In addition, 12% of participants developed ulcers. Venous ulcers are significantly more common than arterial ulcers, Dr. Mejia said. Venous ulcers tend to have a less necrotic base and are in general less painful than arterial ulcers.

In the study, “intractable” ulcers healed after vein stripping surgery, Dr. Mejia said. The treatment also softened lipodermatosclerosis and reduced edema. However, he added, half of the participants required continued compression.

ORLANDO — Approximately half of limbs with varicose veins will have a skin complication, according to a retrospective study.

Venous disease affects an estimated 20% of women and 7% of men in the United States. Patients often present with one or more of these symptoms: aching, tiredness, heaviness in the legs, pain, cramping, swelling, itching, restless legs, and numbness, Ricardo Mejia, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Mejia and his colleague, Lawrence Tretbar, M.D., conducted a 10-month study of skin complications associated with venous disease. They assessed 113 limbs on 105 patients. Participants had surgery for incompetence of the great saphenous vein (102 limbs) or small saphenous vein (11 limbs). The age range was 23–83 years, and 78 of the participants were women. Approximately 50% of limbs (57 total) had skin findings, according to Dr. Mejia of Jupiter, Fla.

Men were 1.5 times more likely to present with dermatologic complications, although varicose veins are three times more common in women. Others at higher risk for skin manifestations include patients with advanced disease or of advanced age, and younger patients if they have a large saphenofemoral junction diameter (greater than 12 mm).

Clinical findings in the study included edema (32% of limbs), hyperpigmentation (24%), lipodermatosclerosis (13%), dermatitis (7%), atrophie blanche (4%), and lymphedema (1%).

In addition, 12% of participants developed ulcers. Venous ulcers are significantly more common than arterial ulcers, Dr. Mejia said. Venous ulcers tend to have a less necrotic base and are in general less painful than arterial ulcers.

In the study, “intractable” ulcers healed after vein stripping surgery, Dr. Mejia said. The treatment also softened lipodermatosclerosis and reduced edema. However, he added, half of the participants required continued compression.

ORLANDO — Approximately half of limbs with varicose veins will have a skin complication, according to a retrospective study.

Venous disease affects an estimated 20% of women and 7% of men in the United States. Patients often present with one or more of these symptoms: aching, tiredness, heaviness in the legs, pain, cramping, swelling, itching, restless legs, and numbness, Ricardo Mejia, M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Mejia and his colleague, Lawrence Tretbar, M.D., conducted a 10-month study of skin complications associated with venous disease. They assessed 113 limbs on 105 patients. Participants had surgery for incompetence of the great saphenous vein (102 limbs) or small saphenous vein (11 limbs). The age range was 23–83 years, and 78 of the participants were women. Approximately 50% of limbs (57 total) had skin findings, according to Dr. Mejia of Jupiter, Fla.

Men were 1.5 times more likely to present with dermatologic complications, although varicose veins are three times more common in women. Others at higher risk for skin manifestations include patients with advanced disease or of advanced age, and younger patients if they have a large saphenofemoral junction diameter (greater than 12 mm).

Clinical findings in the study included edema (32% of limbs), hyperpigmentation (24%), lipodermatosclerosis (13%), dermatitis (7%), atrophie blanche (4%), and lymphedema (1%).

In addition, 12% of participants developed ulcers. Venous ulcers are significantly more common than arterial ulcers, Dr. Mejia said. Venous ulcers tend to have a less necrotic base and are in general less painful than arterial ulcers.

In the study, “intractable” ulcers healed after vein stripping surgery, Dr. Mejia said. The treatment also softened lipodermatosclerosis and reduced edema. However, he added, half of the participants required continued compression.

BOCA RATON, FLA. — A β-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

“There was a very strong relationship between dose and heart rate decrease,” he said. “We have not looked at whether anything in the demographics predicted that change.”

Dr. Colucci has no conflict of interest disclosure regarding Toprol-XL. Its maker, AstraZeneca, sponsored the trial.

BOCA RATON, FLA. — A β-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

“There was a very strong relationship between dose and heart rate decrease,” he said. “We have not looked at whether anything in the demographics predicted that change.”

Dr. Colucci has no conflict of interest disclosure regarding Toprol-XL. Its maker, AstraZeneca, sponsored the trial.

BOCA RATON, FLA. — A β-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

“There was a very strong relationship between dose and heart rate decrease,” he said. “We have not looked at whether anything in the demographics predicted that change.”

Dr. Colucci has no conflict of interest disclosure regarding Toprol-XL. Its maker, AstraZeneca, sponsored the trial.

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Cardiovascular Disease Prevention at the University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus the placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease (28 pg/mL), compared with the placebo group (11 pg/mL). Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet, the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Cardiovascular Disease Prevention at the University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus the placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease (28 pg/mL), compared with the placebo group (11 pg/mL). Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet, the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director of the Rasmussen Center for Cardiovascular Disease Prevention at the University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus the placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease (28 pg/mL), compared with the placebo group (11 pg/mL). Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet, the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.

BOCA RATON, FLA. — A ?-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end-diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end-systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

When asked by an attendee about heart rate changes in the study, Dr. Colucci said, “There was a very strong relationship between dose and heart rate decrease. … We have not looked at whether anything in the demographics predicted that change.”

The REVERT study was sponsored by AstraZeneca. Dr. Colucci has no conflict of interest disclosure regarding the agent studied or AstraZeneca.

BOCA RATON, FLA. — A ?-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end-diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end-systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

When asked by an attendee about heart rate changes in the study, Dr. Colucci said, “There was a very strong relationship between dose and heart rate decrease. … We have not looked at whether anything in the demographics predicted that change.”

The REVERT study was sponsored by AstraZeneca. Dr. Colucci has no conflict of interest disclosure regarding the agent studied or AstraZeneca.

BOCA RATON, FLA. — A ?-blocker can reverse cardiac remodeling and increase left ventricular ejection fraction in asymptomatic heart failure patients, according to a double-blind, randomized, placebo-controlled study presented at the annual meeting of the Heart Failure Society of America.

Metoprolol succinate extended-release tablets (Toprol-XL, AstraZeneca) are indicated for treatment of New York Heart Association class II and III patients with heart failure of ischemic, hypertensive, or cardiomyopathic origin. In symptomatic patients with heart failure and left ventricular systolic dysfunction, Toprol-XL reduced left ventricular volumes after 6 months of treatment in previous research, said Wilson S. Colucci, M.D.

To determine whether the once-daily agent provides a similar benefit in asymptomatic patients, Dr. Colucci and his colleagues randomized 164 NYHA class I patients at 44 U.S. sites to receive a 50-mg or 200-mg dose of metoprolol extended-release tablet daily or placebo.

All the participants in the Reversal of Ventricular Remodeling with Toprol-XL (REVERT) study had a baseline left ventricular ejection fraction (LVEF) below 40%. All also had evidence of cardiac remodeling at baseline, defined as a left ventricular end-diastolic volume index greater than 75 mL/m2. Mean age was 66 years, 25% were women, and 54% had heart failure of an ischemic etiology.

“In heart failure there are progressive enlargement and structural changes to the heart known as remodeling, which is initially compensatory but ultimately maladaptive,” said Dr. Colucci, section chief of cardiovascular medicine at Boston University.

Left ventricular end-systolic volume index was measured echocardiographically after 1 year. This index decreased by 15 mL/m2 with the 200-mg dose of metoprolol, by 8 mL/m2 with the 50-mg dose, and by 4 mL/m2 with placebo. During the same year, LVEF increased 6% with the 200-mg dose, 4% with the 50-mg dose, and 0% with placebo.

“The REVERT study results show a reduction in this measure of left ventricular volume in asymptomatic heart failure patients with left ventricular systolic dysfunction,” and they provide scientific data on cardiac remodeling in such patients, Dr. Colucci said.

The participants received metoprolol or placebo in addition to their existing medications. For example, at study entry, 92% were taking an ACE inhibitor or angiotension receptor blocker, and 65% were taking a diuretic. There were “very minimal changes” in medications during the study, and no participant used a cardiac resynchronization therapy device, he said.

When asked by an attendee about heart rate changes in the study, Dr. Colucci said, “There was a very strong relationship between dose and heart rate decrease. … We have not looked at whether anything in the demographics predicted that change.”

The REVERT study was sponsored by AstraZeneca. Dr. Colucci has no conflict of interest disclosure regarding the agent studied or AstraZeneca.

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking ?-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet; the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking ?-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet; the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with an increase in survival of 43% for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking ?-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America.

Dr. Cohn and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood brain natriuretic peptide (BNP) samples taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota, Minneapolis. There was also a highly significant difference in LVIDd in the treatment group versus placebo group, he added.

A meeting attendee asked about possible variation with the measurements used in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn said.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group experienced a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements in the study.

Another meeting attendee asked how well the BNP values tracked with changes to left ventricular volume. “We don't know that yet; the tracking between the two is not always perfect,” Dr. Cohn said. “BNP is not always perfect. BNP is a continuum, but the lower the better.”

Another audience member asked Dr. Cohn if remodeling was dose dependent. “We haven't looked at that yet,” he replied. “This is really the first look at these data.” He and his associates plan to perform subgroup analyses in the future.

“I would be surprised if the benefit on remodeling is confined to the African American population,” Dr. Cohn said. “We need to do that study.”

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn concluded. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with a 43% increase in survival for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America. He and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood levels of brain natriuretic peptide (BNP) taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and at 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months, there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota in Minneapolis. There also was a highly significant difference in LVIDd in the treatment group versus placebo group.

A meeting attendee asked about possible variation with the measurements in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn responded.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group had a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements.

Another attendee asked how well the BNP values tracked with changes to left ventricular volume. Dr. Cohn said, “We don't know that yet, the tracking between the two is not always perfect. BNP is not always perfect. BNP is a continuum, but the lower the better.”

When asked if remodeling was dose dependent, Dr. Cohn replied, “We haven't looked at that yet.” He and his associates plan to perform subgroup analyses. “I would be surprised if the benefit on remodeling is confined to the African American population,” he said.

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn said. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with a 43% increase in survival for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America. He and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood levels of brain natriuretic peptide (BNP) taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and at 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months, there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota in Minneapolis. There also was a highly significant difference in LVIDd in the treatment group versus placebo group.

A meeting attendee asked about possible variation with the measurements in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn responded.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group had a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements.

Another attendee asked how well the BNP values tracked with changes to left ventricular volume. Dr. Cohn said, “We don't know that yet, the tracking between the two is not always perfect. BNP is not always perfect. BNP is a continuum, but the lower the better.”

When asked if remodeling was dose dependent, Dr. Cohn replied, “We haven't looked at that yet.” He and his associates plan to perform subgroup analyses. “I would be surprised if the benefit on remodeling is confined to the African American population,” he said.

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn said. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

BOCA RATON, FLA. — Fixed-dose isosorbide dinitrate and hydralazine significantly reduces left ventricular volume and increases ejection fraction in African American patients with moderate to severe heart failure, according to a subanalysis of the African American Heart Failure Trial.

Decreases in brain natriuretic peptide corresponded with the 6-month improvements in cardiac remodeling.

In the African American Heart Failure Trial (A-HeFT), the drug combination (BiDil, Nitromed Inc.) was associated with a 43% increase in survival for African Americans with moderate to severe heart failure (N. Engl. J. Med. 2004;351:2049–57). The magnitude of this finding surprised some because the A-HeFT patients were already aggressively treated for heart failure: 87% were already taking β-blockers, 78% were on ACE inhibitors, 39% were on aldosterone inhibitors, and 28% were taking angiotensin receptor blockers.

Regarding A-HeFT mortality, “the survival benefit versus placebo became obvious at 6 months or 7 months, and then the curves spread out remarkably after that,” Jay N. Cohn, M.D., said during a late-breaking clinical trial session at the annual meeting of the Heart Failure Society of America. He and his associates performed a subanalysis of the A-HeFT data to determine whether improvements in left ventricular structure and function could explain the improvement in survival. They compared echocardiographic findings and blood levels of brain natriuretic peptide (BNP) taken at baseline and after 6 months of treatment. One cardiologist evaluated all the digitized echocardiograms in blinded fashion.

Of the 1,050 self-identified African Americans enrolled in A-HeFT, 666 had ejection fraction values recorded at baseline and 6 months. Of this group, 329 were treated with combination therapy and 337 with placebo. In addition, there were 678 participants with left ventricular internal diameter in diastole (LVIDd) values taken at baseline and at 6 months. Of this group, 337 were treated with the combination and 341 with placebo.

At 6 months, there was a significant increase in ejection fraction in the combination group versus placebo, said Dr. Cohn, professor of medicine and director, Rasmussen Center for Cardiovascular Disease Prevention, University of Minnesota in Minneapolis. There also was a highly significant difference in LVIDd in the treatment group versus placebo group.

A meeting attendee asked about possible variation with the measurements in the study. “I'm more comfortable with the consistency of the LVIDd measurements, compared with the ejection fraction measurements, which can be interpreted differently,” Dr. Cohn responded.

The mean baseline BNP level was 300 pg/mL. By 6 months, the treatment group had a greater mean decrease, 28 pg/mL, compared with the placebo group, 11 pg/mL. Dr. Cohn called this a “striking difference between groups” that supports the cardiac remodeling improvements.

Another attendee asked how well the BNP values tracked with changes to left ventricular volume. Dr. Cohn said, “We don't know that yet, the tracking between the two is not always perfect. BNP is not always perfect. BNP is a continuum, but the lower the better.”

When asked if remodeling was dose dependent, Dr. Cohn replied, “We haven't looked at that yet.” He and his associates plan to perform subgroup analyses. “I would be surprised if the benefit on remodeling is confined to the African American population,” he said.

“The combination of isosorbide dinitrate and hydralazine induces regression of left ventricular remodeling in patients already treated with neurohormonal inhibitors,” Dr. Cohn said. “These data provide further support for the growing database that favorable effects on outcomes in heart failure can be attributed to favorable effects on left ventricular structural remodeling.”

ORLANDO — Body mass index alone is not a good indicator of cardiovascular risk in the morbidly obese and should be supplemented with body habitus measures for screening bariatric surgery candidates, Edward H. Livingston, M.D., said at the annual meeting of the American Society for Bariatric Surgery.

“We rely on BMI as the basis of all bariatric surgery criteria. BMI is thought to correlate to morbidity, but the relationship is not perfect,” said Dr. Livingston, professor of surgery at the University of Texas, Dallas.

In an effort to go beyond body mass index (BMI), he and his associates looked at several body habitus measures in 7,634 healthy volunteers who participated in the National Health and Nutrition Examination Survey III (NHANES III).

All subjects were at least age 18 years. The study population was 53% female, and the ethnic breakdown was 41% white, 28% black, 27% Hispanic, and 4% other.

The body habitus measures examined were subcutaneous skinfold thickness, waist circumference, waist/hip ratio, and waist/thigh ratio.

The team analyzed the contribution of these measures to insulin resistance (IR) and diabetes mellitus (DM), two important factors underlying cardiovascular disease.

The measures were analyzed according to gender.

The investigators found significant correlations between all the body measures and IR and DM, except for suprailiac skinfold thickness and development of diabetes in men, Dr. Livingston said.

Interestingly, thigh skinfold thickness was a strong negative predictor for the development of obesity and DM (0.31 odds ratio for diabetes among women and 0.38 among men), Dr. Livingston reported. This suggests that accumulation of fat in the lower body protects against insulin resistance and diabetes mellitus, he noted.

The study indicated that cardiovascular risk profiles actually improved for some people with a BMI over 35 kg/m

For example, triglycerides typically rise as a function of BMI but drop off after 35, Dr. Livingston said.

“If we are operating on the basis of BMI, we are operating on the wrong people,” he said.

“I operate on a large number of patients, and I'm surprised at the small number of cardiovascular complications I see,” Dr. Livingston continued.

“You would expect to see more cardiovascular disease in the population we treat,” he said.

“One reason people get really huge is an unlimited ability to store subcutaneous fat from the food they take in,” he said.

“It may not mean they have an elevated cardiovascular risk,” Dr. Livingston added.

In response to a meeting attendee's question, Dr. Livingston further explained that “the relationship of central obesity to cardiovascular risk factors has been overstated. A number of studies show cardiovascular disease is a function of total upper body fat and not visceral fat.”

The heterogenicity of body fat distribution among obese patients may explain the discrepancy in findings among different studies that have linked BMI to mortality, Dr. Livingston said.

Since 1991, the National Institutes of Health has recommended bariatric surgery for appropriate candidates with a body mass index of 40 or greater. The NIH consensus statement addressed concerns about increased mortality in this patient population.

Although cardiovascular disease is the leading cause of death in the morbidly obese, the relationship to body mass index is not direct, Dr. Livingston pointed out.

The results of the study suggest that body habitus measurements should be incorporated into the routine screening of candidates for bariatric surgery, he asserted.

ORLANDO — Body mass index alone is not a good indicator of cardiovascular risk in the morbidly obese and should be supplemented with body habitus measures for screening bariatric surgery candidates, Edward H. Livingston, M.D., said at the annual meeting of the American Society for Bariatric Surgery.

“We rely on BMI as the basis of all bariatric surgery criteria. BMI is thought to correlate to morbidity, but the relationship is not perfect,” said Dr. Livingston, professor of surgery at the University of Texas, Dallas.

In an effort to go beyond body mass index (BMI), he and his associates looked at several body habitus measures in 7,634 healthy volunteers who participated in the National Health and Nutrition Examination Survey III (NHANES III).

All subjects were at least age 18 years. The study population was 53% female, and the ethnic breakdown was 41% white, 28% black, 27% Hispanic, and 4% other.

The body habitus measures examined were subcutaneous skinfold thickness, waist circumference, waist/hip ratio, and waist/thigh ratio.

The team analyzed the contribution of these measures to insulin resistance (IR) and diabetes mellitus (DM), two important factors underlying cardiovascular disease.

The measures were analyzed according to gender.

The investigators found significant correlations between all the body measures and IR and DM, except for suprailiac skinfold thickness and development of diabetes in men, Dr. Livingston said.

Interestingly, thigh skinfold thickness was a strong negative predictor for the development of obesity and DM (0.31 odds ratio for diabetes among women and 0.38 among men), Dr. Livingston reported. This suggests that accumulation of fat in the lower body protects against insulin resistance and diabetes mellitus, he noted.

The study indicated that cardiovascular risk profiles actually improved for some people with a BMI over 35 kg/m

For example, triglycerides typically rise as a function of BMI but drop off after 35, Dr. Livingston said.

“If we are operating on the basis of BMI, we are operating on the wrong people,” he said.

“I operate on a large number of patients, and I'm surprised at the small number of cardiovascular complications I see,” Dr. Livingston continued.

“You would expect to see more cardiovascular disease in the population we treat,” he said.

“One reason people get really huge is an unlimited ability to store subcutaneous fat from the food they take in,” he said.

“It may not mean they have an elevated cardiovascular risk,” Dr. Livingston added.

In response to a meeting attendee's question, Dr. Livingston further explained that “the relationship of central obesity to cardiovascular risk factors has been overstated. A number of studies show cardiovascular disease is a function of total upper body fat and not visceral fat.”

The heterogenicity of body fat distribution among obese patients may explain the discrepancy in findings among different studies that have linked BMI to mortality, Dr. Livingston said.

Since 1991, the National Institutes of Health has recommended bariatric surgery for appropriate candidates with a body mass index of 40 or greater. The NIH consensus statement addressed concerns about increased mortality in this patient population.

Although cardiovascular disease is the leading cause of death in the morbidly obese, the relationship to body mass index is not direct, Dr. Livingston pointed out.

The results of the study suggest that body habitus measurements should be incorporated into the routine screening of candidates for bariatric surgery, he asserted.

ORLANDO — Body mass index alone is not a good indicator of cardiovascular risk in the morbidly obese and should be supplemented with body habitus measures for screening bariatric surgery candidates, Edward H. Livingston, M.D., said at the annual meeting of the American Society for Bariatric Surgery.

“We rely on BMI as the basis of all bariatric surgery criteria. BMI is thought to correlate to morbidity, but the relationship is not perfect,” said Dr. Livingston, professor of surgery at the University of Texas, Dallas.

In an effort to go beyond body mass index (BMI), he and his associates looked at several body habitus measures in 7,634 healthy volunteers who participated in the National Health and Nutrition Examination Survey III (NHANES III).

All subjects were at least age 18 years. The study population was 53% female, and the ethnic breakdown was 41% white, 28% black, 27% Hispanic, and 4% other.

The body habitus measures examined were subcutaneous skinfold thickness, waist circumference, waist/hip ratio, and waist/thigh ratio.

The team analyzed the contribution of these measures to insulin resistance (IR) and diabetes mellitus (DM), two important factors underlying cardiovascular disease.

The measures were analyzed according to gender.

The investigators found significant correlations between all the body measures and IR and DM, except for suprailiac skinfold thickness and development of diabetes in men, Dr. Livingston said.

Interestingly, thigh skinfold thickness was a strong negative predictor for the development of obesity and DM (0.31 odds ratio for diabetes among women and 0.38 among men), Dr. Livingston reported. This suggests that accumulation of fat in the lower body protects against insulin resistance and diabetes mellitus, he noted.

The study indicated that cardiovascular risk profiles actually improved for some people with a BMI over 35 kg/m

For example, triglycerides typically rise as a function of BMI but drop off after 35, Dr. Livingston said.

“If we are operating on the basis of BMI, we are operating on the wrong people,” he said.

“I operate on a large number of patients, and I'm surprised at the small number of cardiovascular complications I see,” Dr. Livingston continued.

“You would expect to see more cardiovascular disease in the population we treat,” he said.

“One reason people get really huge is an unlimited ability to store subcutaneous fat from the food they take in,” he said.

“It may not mean they have an elevated cardiovascular risk,” Dr. Livingston added.

In response to a meeting attendee's question, Dr. Livingston further explained that “the relationship of central obesity to cardiovascular risk factors has been overstated. A number of studies show cardiovascular disease is a function of total upper body fat and not visceral fat.”

The heterogenicity of body fat distribution among obese patients may explain the discrepancy in findings among different studies that have linked BMI to mortality, Dr. Livingston said.

Since 1991, the National Institutes of Health has recommended bariatric surgery for appropriate candidates with a body mass index of 40 or greater. The NIH consensus statement addressed concerns about increased mortality in this patient population.

Although cardiovascular disease is the leading cause of death in the morbidly obese, the relationship to body mass index is not direct, Dr. Livingston pointed out.

The results of the study suggest that body habitus measurements should be incorporated into the routine screening of candidates for bariatric surgery, he asserted.