Mitchel L. Zoler, PhD

Major Findings: Left-ventricular mass in children grew by 4% in the past 2 decades, and body mass index was linked to the increased mass.

Source of Data: Retrospective study of 700 children examined at Cincinnati Children's Hospital during 1986-1988 and 2008.

Disclosures: Dr. Crowley had no financial disclosures for the study.

ORLANDO — A growing number of American children have increased left ventricular mass, a marker for cardiovascular disease risk.

The finding was noted in a study that included 700 children and “is the first study to look at average left ventricular mass in the whole pediatric population,” according to Dr. David I. Crowley, a pediatric cardiologist at Cincinnati Children's Hospital.

In children with an average age of 10 years, mean left ventricular mass rose by a statistically significant 4% from 1986 to 2008. The prevalence of left ventricular hypertrophy in the children more than doubled, from 7% to 15%, Dr. Crowley said at the annual scientific sessions of the American Heart Association.

The increase appears to be linked to obesity.

In the 1986-1988 cohort of 350 children examined at Cincinnati Children's, the prevalence of overweight was 14% and of obesity was 5%.

In a matched cohort of 350 children assessed in 2008, the prevalence of overweight was 15% but the prevalence of obesity soared to 19%.

Results from a multivariate analysis showed that body mass index was a major determinant of left ventricular mass, Dr. Crowley said.

The study included children aged 2-19 years.

The participants came to Cincinnati Children's in 1986-1988 for an echocardiography examination because of a murmur, palpitations, syncope, or chest pain.

All 350 children included in the analysis had normal cardiac anatomy and function, and none had systemic disease or a body mass index of 40 kg/m

Dr. Crowley and his associates identified 350 children matched by age and gender who underwent echocardiography at their center during 2008 for similar reasons and met similar clinical criteria.

Both cohorts were 60% boys, and 82% or 83% were white.

Analysis of the echocardiographic data showed that, in addition to having larger hearts, the more recently evaluated children also had a greater prevalence of high-risk cardiac morphology.

The prevalence of eccentric hypertrophy was 6% in the 1986-1988 group and 12% in the 2008 cohort.

The prevalence of concentric hypertrophy also doubled in the more recent cohort.

Although average left ventricular mass rose by only 4% from the older to more contemporary cohort, this difference is important, commented Dr. Stephen R. Daniels.

“When you look at a population and a value gets worse by even a small amount, it suggests that many more in the population may now be in a high-risk category,” said Dr. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado in Denver.

Major Findings: Left-ventricular mass in children grew by 4% in the past 2 decades, and body mass index was linked to the increased mass.

Source of Data: Retrospective study of 700 children examined at Cincinnati Children's Hospital during 1986-1988 and 2008.

Disclosures: Dr. Crowley had no financial disclosures for the study.

ORLANDO — A growing number of American children have increased left ventricular mass, a marker for cardiovascular disease risk.

The finding was noted in a study that included 700 children and “is the first study to look at average left ventricular mass in the whole pediatric population,” according to Dr. David I. Crowley, a pediatric cardiologist at Cincinnati Children's Hospital.

In children with an average age of 10 years, mean left ventricular mass rose by a statistically significant 4% from 1986 to 2008. The prevalence of left ventricular hypertrophy in the children more than doubled, from 7% to 15%, Dr. Crowley said at the annual scientific sessions of the American Heart Association.

The increase appears to be linked to obesity.

In the 1986-1988 cohort of 350 children examined at Cincinnati Children's, the prevalence of overweight was 14% and of obesity was 5%.

In a matched cohort of 350 children assessed in 2008, the prevalence of overweight was 15% but the prevalence of obesity soared to 19%.

Results from a multivariate analysis showed that body mass index was a major determinant of left ventricular mass, Dr. Crowley said.

The study included children aged 2-19 years.

The participants came to Cincinnati Children's in 1986-1988 for an echocardiography examination because of a murmur, palpitations, syncope, or chest pain.

All 350 children included in the analysis had normal cardiac anatomy and function, and none had systemic disease or a body mass index of 40 kg/m

Dr. Crowley and his associates identified 350 children matched by age and gender who underwent echocardiography at their center during 2008 for similar reasons and met similar clinical criteria.

Both cohorts were 60% boys, and 82% or 83% were white.

Analysis of the echocardiographic data showed that, in addition to having larger hearts, the more recently evaluated children also had a greater prevalence of high-risk cardiac morphology.

The prevalence of eccentric hypertrophy was 6% in the 1986-1988 group and 12% in the 2008 cohort.

The prevalence of concentric hypertrophy also doubled in the more recent cohort.

Although average left ventricular mass rose by only 4% from the older to more contemporary cohort, this difference is important, commented Dr. Stephen R. Daniels.

“When you look at a population and a value gets worse by even a small amount, it suggests that many more in the population may now be in a high-risk category,” said Dr. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado in Denver.

Major Findings: Left-ventricular mass in children grew by 4% in the past 2 decades, and body mass index was linked to the increased mass.

Source of Data: Retrospective study of 700 children examined at Cincinnati Children's Hospital during 1986-1988 and 2008.

Disclosures: Dr. Crowley had no financial disclosures for the study.

ORLANDO — A growing number of American children have increased left ventricular mass, a marker for cardiovascular disease risk.

The finding was noted in a study that included 700 children and “is the first study to look at average left ventricular mass in the whole pediatric population,” according to Dr. David I. Crowley, a pediatric cardiologist at Cincinnati Children's Hospital.

In children with an average age of 10 years, mean left ventricular mass rose by a statistically significant 4% from 1986 to 2008. The prevalence of left ventricular hypertrophy in the children more than doubled, from 7% to 15%, Dr. Crowley said at the annual scientific sessions of the American Heart Association.

The increase appears to be linked to obesity.

In the 1986-1988 cohort of 350 children examined at Cincinnati Children's, the prevalence of overweight was 14% and of obesity was 5%.

In a matched cohort of 350 children assessed in 2008, the prevalence of overweight was 15% but the prevalence of obesity soared to 19%.

Results from a multivariate analysis showed that body mass index was a major determinant of left ventricular mass, Dr. Crowley said.

The study included children aged 2-19 years.

The participants came to Cincinnati Children's in 1986-1988 for an echocardiography examination because of a murmur, palpitations, syncope, or chest pain.

All 350 children included in the analysis had normal cardiac anatomy and function, and none had systemic disease or a body mass index of 40 kg/m

Dr. Crowley and his associates identified 350 children matched by age and gender who underwent echocardiography at their center during 2008 for similar reasons and met similar clinical criteria.

Both cohorts were 60% boys, and 82% or 83% were white.

Analysis of the echocardiographic data showed that, in addition to having larger hearts, the more recently evaluated children also had a greater prevalence of high-risk cardiac morphology.

The prevalence of eccentric hypertrophy was 6% in the 1986-1988 group and 12% in the 2008 cohort.

The prevalence of concentric hypertrophy also doubled in the more recent cohort.

Although average left ventricular mass rose by only 4% from the older to more contemporary cohort, this difference is important, commented Dr. Stephen R. Daniels.

“When you look at a population and a value gets worse by even a small amount, it suggests that many more in the population may now be in a high-risk category,” said Dr. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado in Denver.

PHILADELPHIA — Weight loss was linked to significant drops in serum uric acid levels in a prospective study of 12,510 men with high cardiovascular risk.

“Weight loss could substantially help achieve a widely accepted therapeutic uric acid target level of 6 mg/dL among men with a high cardiovascular risk profile,” Yanyan Zhu said at the annual meeting of the American College of Rheumatology.

Ms. Zhu and her associates used data from men with a high cardiovascular risk profile enrolled in the Multiple Risk Factor Intervention trial, a study begun in the early 1970s. The trial assessed the role of multiple risk-factor interventions, including a special diet, on mortality from coronary heart disease.

The men were aged 35-57 years at baseline (mean age 46 years). Their average body mass index was 28 kg/m

The men returned annually for clinical assessments for 6 years. During follow-up, 39% had weight loss, 31% had no weight change, and 30% gained weight.

In an analysis adjusted for baseline covariables of hypertension, diuretic use, alcohol use, and serum creatinine, men who lost weight during follow-up had a statistically significant reduction in their risk for having hyperuricemia, said Ms. Zhu, an epidemiologist at Boston University. Men who gained weight during follow-up had a significant increased risk for hyperuricemia (see table).

A second analysis showed similar, significant relationships between changes in weight and changes in the serum level of uric acid. The more weight patients lost the lower their uric acid levels fell. The more weight they gained the higher their levels rose (see table).

Ms. Zhu and her associates hypothesized that the impact of weight change on serum uric acid occurred through changes in uric acid production and renal excretion. For example, reduced adiposity leads to lower insulin levels, which produces increased renal excretion of uric acid.

Disclosures: Ms. Zhu said she had no conflicts of interest. Some of her associates had financial ties to Takeda, which markets a drug for lowering uric acid levels. One associate served on an advisory board for Savient, which is developing a uric acid lowering drug, and another formerly held stock in Savient.

Men who lost weight had a statistically significant reduction in their risk for having hyperuricemia.

Source MS. ZHU

Elsevier Global Medical News

PHILADELPHIA — Weight loss was linked to significant drops in serum uric acid levels in a prospective study of 12,510 men with high cardiovascular risk.

“Weight loss could substantially help achieve a widely accepted therapeutic uric acid target level of 6 mg/dL among men with a high cardiovascular risk profile,” Yanyan Zhu said at the annual meeting of the American College of Rheumatology.

Ms. Zhu and her associates used data from men with a high cardiovascular risk profile enrolled in the Multiple Risk Factor Intervention trial, a study begun in the early 1970s. The trial assessed the role of multiple risk-factor interventions, including a special diet, on mortality from coronary heart disease.

The men were aged 35-57 years at baseline (mean age 46 years). Their average body mass index was 28 kg/m

The men returned annually for clinical assessments for 6 years. During follow-up, 39% had weight loss, 31% had no weight change, and 30% gained weight.

In an analysis adjusted for baseline covariables of hypertension, diuretic use, alcohol use, and serum creatinine, men who lost weight during follow-up had a statistically significant reduction in their risk for having hyperuricemia, said Ms. Zhu, an epidemiologist at Boston University. Men who gained weight during follow-up had a significant increased risk for hyperuricemia (see table).

A second analysis showed similar, significant relationships between changes in weight and changes in the serum level of uric acid. The more weight patients lost the lower their uric acid levels fell. The more weight they gained the higher their levels rose (see table).

Ms. Zhu and her associates hypothesized that the impact of weight change on serum uric acid occurred through changes in uric acid production and renal excretion. For example, reduced adiposity leads to lower insulin levels, which produces increased renal excretion of uric acid.

Disclosures: Ms. Zhu said she had no conflicts of interest. Some of her associates had financial ties to Takeda, which markets a drug for lowering uric acid levels. One associate served on an advisory board for Savient, which is developing a uric acid lowering drug, and another formerly held stock in Savient.

Men who lost weight had a statistically significant reduction in their risk for having hyperuricemia.

Source MS. ZHU

Elsevier Global Medical News

PHILADELPHIA — Weight loss was linked to significant drops in serum uric acid levels in a prospective study of 12,510 men with high cardiovascular risk.

“Weight loss could substantially help achieve a widely accepted therapeutic uric acid target level of 6 mg/dL among men with a high cardiovascular risk profile,” Yanyan Zhu said at the annual meeting of the American College of Rheumatology.

Ms. Zhu and her associates used data from men with a high cardiovascular risk profile enrolled in the Multiple Risk Factor Intervention trial, a study begun in the early 1970s. The trial assessed the role of multiple risk-factor interventions, including a special diet, on mortality from coronary heart disease.

The men were aged 35-57 years at baseline (mean age 46 years). Their average body mass index was 28 kg/m

The men returned annually for clinical assessments for 6 years. During follow-up, 39% had weight loss, 31% had no weight change, and 30% gained weight.

In an analysis adjusted for baseline covariables of hypertension, diuretic use, alcohol use, and serum creatinine, men who lost weight during follow-up had a statistically significant reduction in their risk for having hyperuricemia, said Ms. Zhu, an epidemiologist at Boston University. Men who gained weight during follow-up had a significant increased risk for hyperuricemia (see table).

A second analysis showed similar, significant relationships between changes in weight and changes in the serum level of uric acid. The more weight patients lost the lower their uric acid levels fell. The more weight they gained the higher their levels rose (see table).

Ms. Zhu and her associates hypothesized that the impact of weight change on serum uric acid occurred through changes in uric acid production and renal excretion. For example, reduced adiposity leads to lower insulin levels, which produces increased renal excretion of uric acid.

Disclosures: Ms. Zhu said she had no conflicts of interest. Some of her associates had financial ties to Takeda, which markets a drug for lowering uric acid levels. One associate served on an advisory board for Savient, which is developing a uric acid lowering drug, and another formerly held stock in Savient.

Men who lost weight had a statistically significant reduction in their risk for having hyperuricemia.

Source MS. ZHU

Elsevier Global Medical News

ORLANDO — Bariatric surgery produces rapid, dramatic improvements in obese adolescents, but at 6 months post surgery they hit a wall and further gains in their clinical status usually do not occur, according to a follow-up study of 44 patients.

“There is generally a plateau [of weight loss] at about 6-12 months, and sometimes a creep-up after 1 year. Even though [these adolescents] are significantly better, they're still not normal, so we should intervene even sooner,” Dr. Holly M. Ippisch said at the annual scientific sessions of the American Heart Association.

In a series of 87 adolescents who underwent Roux-en-Y bariatric surgery at Cincinnati Children's Hospital Medical Center, average body mass index dropped from 58 kg/m

Cardiovascular measures showed a similar pattern, with substantial improvements in parameters such as left ventricular mass and diastolic dysfunction during the first 6 months following surgery, followed by a leveling off to values that remained abnormally high and potentially dangerous.

Diminishing weight loss more than 6 months out from surgery “is very interesting and is being seen at a number of U.S. centers” doing bariatric surgery on adolescents, said Dr. Stephen R. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado, Denver. “It's something that we don't understand and need to learn more about. From what we can tell they are in general eating in a healthy way,” he said in an interview.

At Cincinnati Children's and other centers, adolescents who are candidates for bariatric surgery must have a BMI of at least 40 kg/m

When bariatric surgery for adolescents began a few years ago, “the thought was to be as conservative as possible, and reserve it for only the most severely affected adolescents,” he added.

“We didn't know if it was safe for adolescents, so it was reserved for extreme cases,” added Dr. Ippisch.

But the plateauing effect now being widely seen “is starting a thought process on what the criteria should be,” Dr. Daniels said.

The 87 adolescents who underwent Roux-en-Y surgery in Cincinnati were aged 13-19 years; three-quarters were girls. Their average left ventricular mass at baseline was 52 g/m

Another way that Dr. Ippisch assessed left ventricular size and shape was to divide patients into four risk categories: normal (low-risk), concentric remodeling (mildly elevated risk), eccentric ventricular hypertrophy (moderately elevated risk), and concentric ventricular hypertrophy (highest risk). The patients showed a shift from half having normal-shaped hearts at baseline to about 80% with normal shapes at 6, 12, and 24 months follow-up (see chart).

The patients also had an elevated left ventricular end diastolic pressure at baseline, an average mitral E/Ea ratio of about 7.0, indicating diastolic dysfunction, that improved to an average ratio of about 6.0 after 6 months and remained at that level through 2 years of follow-up. Other improvements included heart rate, which fell from an average of 83 bpm at baseline to 63 bpm at 6 months and 61 bpm at 2 years, and blood pressure, which dropped from an average of 121/69 mm Hg at baseline to an average of 113/65 mm Hg at 6 months and 114/66 mm Hg at 2 years.

Dr. Ippisch had no commercial financial disclosures for this study.

Cardiovascular parameters leveled off to abnormally high and potentially dangerous values.

Source DR. IPPISCH

Elsevier Global Medical News

ORLANDO — Bariatric surgery produces rapid, dramatic improvements in obese adolescents, but at 6 months post surgery they hit a wall and further gains in their clinical status usually do not occur, according to a follow-up study of 44 patients.

“There is generally a plateau [of weight loss] at about 6-12 months, and sometimes a creep-up after 1 year. Even though [these adolescents] are significantly better, they're still not normal, so we should intervene even sooner,” Dr. Holly M. Ippisch said at the annual scientific sessions of the American Heart Association.

In a series of 87 adolescents who underwent Roux-en-Y bariatric surgery at Cincinnati Children's Hospital Medical Center, average body mass index dropped from 58 kg/m

Cardiovascular measures showed a similar pattern, with substantial improvements in parameters such as left ventricular mass and diastolic dysfunction during the first 6 months following surgery, followed by a leveling off to values that remained abnormally high and potentially dangerous.

Diminishing weight loss more than 6 months out from surgery “is very interesting and is being seen at a number of U.S. centers” doing bariatric surgery on adolescents, said Dr. Stephen R. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado, Denver. “It's something that we don't understand and need to learn more about. From what we can tell they are in general eating in a healthy way,” he said in an interview.

At Cincinnati Children's and other centers, adolescents who are candidates for bariatric surgery must have a BMI of at least 40 kg/m

When bariatric surgery for adolescents began a few years ago, “the thought was to be as conservative as possible, and reserve it for only the most severely affected adolescents,” he added.

“We didn't know if it was safe for adolescents, so it was reserved for extreme cases,” added Dr. Ippisch.

But the plateauing effect now being widely seen “is starting a thought process on what the criteria should be,” Dr. Daniels said.

The 87 adolescents who underwent Roux-en-Y surgery in Cincinnati were aged 13-19 years; three-quarters were girls. Their average left ventricular mass at baseline was 52 g/m

Another way that Dr. Ippisch assessed left ventricular size and shape was to divide patients into four risk categories: normal (low-risk), concentric remodeling (mildly elevated risk), eccentric ventricular hypertrophy (moderately elevated risk), and concentric ventricular hypertrophy (highest risk). The patients showed a shift from half having normal-shaped hearts at baseline to about 80% with normal shapes at 6, 12, and 24 months follow-up (see chart).

The patients also had an elevated left ventricular end diastolic pressure at baseline, an average mitral E/Ea ratio of about 7.0, indicating diastolic dysfunction, that improved to an average ratio of about 6.0 after 6 months and remained at that level through 2 years of follow-up. Other improvements included heart rate, which fell from an average of 83 bpm at baseline to 63 bpm at 6 months and 61 bpm at 2 years, and blood pressure, which dropped from an average of 121/69 mm Hg at baseline to an average of 113/65 mm Hg at 6 months and 114/66 mm Hg at 2 years.

Dr. Ippisch had no commercial financial disclosures for this study.

Cardiovascular parameters leveled off to abnormally high and potentially dangerous values.

Source DR. IPPISCH

Elsevier Global Medical News

ORLANDO — Bariatric surgery produces rapid, dramatic improvements in obese adolescents, but at 6 months post surgery they hit a wall and further gains in their clinical status usually do not occur, according to a follow-up study of 44 patients.

“There is generally a plateau [of weight loss] at about 6-12 months, and sometimes a creep-up after 1 year. Even though [these adolescents] are significantly better, they're still not normal, so we should intervene even sooner,” Dr. Holly M. Ippisch said at the annual scientific sessions of the American Heart Association.

In a series of 87 adolescents who underwent Roux-en-Y bariatric surgery at Cincinnati Children's Hospital Medical Center, average body mass index dropped from 58 kg/m

Cardiovascular measures showed a similar pattern, with substantial improvements in parameters such as left ventricular mass and diastolic dysfunction during the first 6 months following surgery, followed by a leveling off to values that remained abnormally high and potentially dangerous.

Diminishing weight loss more than 6 months out from surgery “is very interesting and is being seen at a number of U.S. centers” doing bariatric surgery on adolescents, said Dr. Stephen R. Daniels, a pediatric cardiologist and professor and chairman of pediatrics at the University of Colorado, Denver. “It's something that we don't understand and need to learn more about. From what we can tell they are in general eating in a healthy way,” he said in an interview.

At Cincinnati Children's and other centers, adolescents who are candidates for bariatric surgery must have a BMI of at least 40 kg/m

When bariatric surgery for adolescents began a few years ago, “the thought was to be as conservative as possible, and reserve it for only the most severely affected adolescents,” he added.

“We didn't know if it was safe for adolescents, so it was reserved for extreme cases,” added Dr. Ippisch.

But the plateauing effect now being widely seen “is starting a thought process on what the criteria should be,” Dr. Daniels said.

The 87 adolescents who underwent Roux-en-Y surgery in Cincinnati were aged 13-19 years; three-quarters were girls. Their average left ventricular mass at baseline was 52 g/m

Another way that Dr. Ippisch assessed left ventricular size and shape was to divide patients into four risk categories: normal (low-risk), concentric remodeling (mildly elevated risk), eccentric ventricular hypertrophy (moderately elevated risk), and concentric ventricular hypertrophy (highest risk). The patients showed a shift from half having normal-shaped hearts at baseline to about 80% with normal shapes at 6, 12, and 24 months follow-up (see chart).

The patients also had an elevated left ventricular end diastolic pressure at baseline, an average mitral E/Ea ratio of about 7.0, indicating diastolic dysfunction, that improved to an average ratio of about 6.0 after 6 months and remained at that level through 2 years of follow-up. Other improvements included heart rate, which fell from an average of 83 bpm at baseline to 63 bpm at 6 months and 61 bpm at 2 years, and blood pressure, which dropped from an average of 121/69 mm Hg at baseline to an average of 113/65 mm Hg at 6 months and 114/66 mm Hg at 2 years.

Dr. Ippisch had no commercial financial disclosures for this study.

Cardiovascular parameters leveled off to abnormally high and potentially dangerous values.

Source DR. IPPISCH

Elsevier Global Medical News

ORLANDO — Patients with heart failure had a greater than twofold increased risk of developing diabetes compared with people without heart failure in a review of more than 4,600 individuals in the Framingham Offspring Study.

The analysis showed a strong association between severity of heart failure (HF) symptoms and risk for new-onset diabetes: Patients with higher New York Association Class HF faced a greater risk for developing diabetes than did patients with less severe HF symptoms, Dr. Ankit Rathod said at the annual scientific sessions of the American Heart Association.

The implications are that patients with HF should undergo more intensive surveillance for development of insulin resistance and diabetes. The findings also present a new reason for optimized HF treatment to minimize symptom severity because this may cut the patient's risk for developing diabetes, Dr. Rathod said in an interview.

The hypothesized causal link between HF and diabetes is the neurohormonal, sympathetic activation that characterizes HF. This leads to norepinephrine release, which can trigger insulin resistance and hence increased susceptibility to developing diabetes, said Dr. Rathod, an internal medicine physician at Wayne State University, Detroit. In addition, patients with more severe HF symptoms have reduced activity, which might exacerbate insulin resistance and the risk for developing diabetes.

“I believe the connections between insulin resistance and neurohormonal activation are a real phenomenon,” said Dr. Clyde W. Yancy, medical director of the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas. He cited study results showing that treatment with drugs that block neurohormonal activation also cut development of diabetes, such as with ramipril in the HOPE study (N. Engl. J. Med 2000;342:145-53) and treatment with carvedilol in the CAPRICORN study (Lancet 2001;357:1385-90).

Dr. Rathod's study used data collected from the more than 4,900 people enrolled into the Framingham Offspring Study in 1971. He and his associates excluded people with a history of diabetes or HF at the time of enrollment, as well as those who had missing data on their subsequent rate of new-onset diabetes. The 4,614 people included in the study had an average age of 35, and about half were women.

During an average follow-up of 24 years, 123 developed HF, and 468 developed new-onset diabetes. Forty-one of the 123 patients (33%) who developed HF later developed diabetes, compared with 427 new cases of diabetes among the other 4,491 people (10%).

In a multivariate analysis that adjusted for baseline demographic and clinical differences, including drug treatments and baseline blood glucose levels, patients who first developed HF had a statistically significant 2.5-fold increased risk for later developing diabetes compared with those who did not have HF.

The link between HF and diabetes should be examined in other databases, Dr. Rathod said. He and Dr. Yancy disclosed having no financial conflicts of interest.

Patients who first developed HF had a statistically significant 2.5-fold increased risk for future diabetes.

Source DR. RATHOD

ORLANDO — Patients with heart failure had a greater than twofold increased risk of developing diabetes compared with people without heart failure in a review of more than 4,600 individuals in the Framingham Offspring Study.

The analysis showed a strong association between severity of heart failure (HF) symptoms and risk for new-onset diabetes: Patients with higher New York Association Class HF faced a greater risk for developing diabetes than did patients with less severe HF symptoms, Dr. Ankit Rathod said at the annual scientific sessions of the American Heart Association.

The implications are that patients with HF should undergo more intensive surveillance for development of insulin resistance and diabetes. The findings also present a new reason for optimized HF treatment to minimize symptom severity because this may cut the patient's risk for developing diabetes, Dr. Rathod said in an interview.

The hypothesized causal link between HF and diabetes is the neurohormonal, sympathetic activation that characterizes HF. This leads to norepinephrine release, which can trigger insulin resistance and hence increased susceptibility to developing diabetes, said Dr. Rathod, an internal medicine physician at Wayne State University, Detroit. In addition, patients with more severe HF symptoms have reduced activity, which might exacerbate insulin resistance and the risk for developing diabetes.

“I believe the connections between insulin resistance and neurohormonal activation are a real phenomenon,” said Dr. Clyde W. Yancy, medical director of the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas. He cited study results showing that treatment with drugs that block neurohormonal activation also cut development of diabetes, such as with ramipril in the HOPE study (N. Engl. J. Med 2000;342:145-53) and treatment with carvedilol in the CAPRICORN study (Lancet 2001;357:1385-90).

Dr. Rathod's study used data collected from the more than 4,900 people enrolled into the Framingham Offspring Study in 1971. He and his associates excluded people with a history of diabetes or HF at the time of enrollment, as well as those who had missing data on their subsequent rate of new-onset diabetes. The 4,614 people included in the study had an average age of 35, and about half were women.

During an average follow-up of 24 years, 123 developed HF, and 468 developed new-onset diabetes. Forty-one of the 123 patients (33%) who developed HF later developed diabetes, compared with 427 new cases of diabetes among the other 4,491 people (10%).

In a multivariate analysis that adjusted for baseline demographic and clinical differences, including drug treatments and baseline blood glucose levels, patients who first developed HF had a statistically significant 2.5-fold increased risk for later developing diabetes compared with those who did not have HF.

The link between HF and diabetes should be examined in other databases, Dr. Rathod said. He and Dr. Yancy disclosed having no financial conflicts of interest.

Patients who first developed HF had a statistically significant 2.5-fold increased risk for future diabetes.

Source DR. RATHOD

ORLANDO — Patients with heart failure had a greater than twofold increased risk of developing diabetes compared with people without heart failure in a review of more than 4,600 individuals in the Framingham Offspring Study.

The analysis showed a strong association between severity of heart failure (HF) symptoms and risk for new-onset diabetes: Patients with higher New York Association Class HF faced a greater risk for developing diabetes than did patients with less severe HF symptoms, Dr. Ankit Rathod said at the annual scientific sessions of the American Heart Association.

The implications are that patients with HF should undergo more intensive surveillance for development of insulin resistance and diabetes. The findings also present a new reason for optimized HF treatment to minimize symptom severity because this may cut the patient's risk for developing diabetes, Dr. Rathod said in an interview.

The hypothesized causal link between HF and diabetes is the neurohormonal, sympathetic activation that characterizes HF. This leads to norepinephrine release, which can trigger insulin resistance and hence increased susceptibility to developing diabetes, said Dr. Rathod, an internal medicine physician at Wayne State University, Detroit. In addition, patients with more severe HF symptoms have reduced activity, which might exacerbate insulin resistance and the risk for developing diabetes.

“I believe the connections between insulin resistance and neurohormonal activation are a real phenomenon,” said Dr. Clyde W. Yancy, medical director of the Baylor Heart and Vascular Institute at Baylor University Medical Center in Dallas. He cited study results showing that treatment with drugs that block neurohormonal activation also cut development of diabetes, such as with ramipril in the HOPE study (N. Engl. J. Med 2000;342:145-53) and treatment with carvedilol in the CAPRICORN study (Lancet 2001;357:1385-90).

Dr. Rathod's study used data collected from the more than 4,900 people enrolled into the Framingham Offspring Study in 1971. He and his associates excluded people with a history of diabetes or HF at the time of enrollment, as well as those who had missing data on their subsequent rate of new-onset diabetes. The 4,614 people included in the study had an average age of 35, and about half were women.

During an average follow-up of 24 years, 123 developed HF, and 468 developed new-onset diabetes. Forty-one of the 123 patients (33%) who developed HF later developed diabetes, compared with 427 new cases of diabetes among the other 4,491 people (10%).

In a multivariate analysis that adjusted for baseline demographic and clinical differences, including drug treatments and baseline blood glucose levels, patients who first developed HF had a statistically significant 2.5-fold increased risk for later developing diabetes compared with those who did not have HF.

The link between HF and diabetes should be examined in other databases, Dr. Rathod said. He and Dr. Yancy disclosed having no financial conflicts of interest.

Patients who first developed HF had a statistically significant 2.5-fold increased risk for future diabetes.

Source DR. RATHOD

ORLANDO — In elderly patients with diabetes and no history of coronary artery or peripheral artery disease, exercise capacity less than 85% of predicted independently identified patients at increased risk for death, stroke, or myocardial infarction in a study of more than 600 patients.

“This is the first study in patients with diabetes and without known coronary artery disease” to show that functional capacity predicts outcome, Dr. Wilbert S. Aronow said at the annual scientific sessions of the American Heart Association.

The finding suggests more aggressive use of a treadmill exercise sestamibi stress test (TESST) to screen patients with diabetes, especially as they get older. “Zero in on these patients; they are at greater risk,” said Dr. Aronow, a cardiologist at New York Medical College in Valhalla. Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment by lipid-lowering drugs and blood pressure control, regardless of the extent of their vascular disease.

“Especially in elderly patients with long-duration diabetes, the [management] approach should focus on blood pressure and on lowering low-density lipoprotein cholesterol,” commented Dr. Prakash C. Deedwania, professor of medicine and chief of cardiology at the University of California, San Francisco, in Fresno.

The study included 609 consecutive patients with diabetes and no history of coronary artery disease, peripheral artery disease, pulmonary disease, or diabetic neuropathy. Their average age was 70 years. All patients underwent a TESST, the duration of which was limited by dyspnea in all cases; none of the patients had chest pain during the exercise test.

Dr. Aronow and his associates calculated the percentage of predicted exercise each person achieved based on their age and sex. A peak exercise level less than 85% of predicted occurred in 301 patients (49%), and a level of 85% or greater occurred in the other 308 (51%). The two subgroups had similar profiles for age, sex, race, smoking prevalence, hypertension, dyslipidemia, body mass index, renal function, duration of diabetes, and use of insulin, aspirin, statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers. In all, 241 of the patients also underwent coronary angiography, including 128 patients from the low exercise–capacity group and 113 from the group with a level of 85% or greater.

Angiography revealed multivessel obstructive coronary disease in 38% of the low exercise–capacity patients and in 18% of the higher exercise–capacity patients, a statistically significant difference.

After an average follow-up of 47 months, low exercise–capacity patients had a mortality rate of 10%, and a combined rate of death, myocardial infarction, or stroke of 21%. In contrast, the higher exercise–capacity patients had a mortality rate of 4% and a combined event rate of 12%, statistically significant differences between the two subgroups.

A multivariate analysis that controlled for 20 baseline variables showed that patients with an exercise capacity of 85% or greater had a significant 48% reduced risk for death, myocardial infarction, or stroke, compared with the other group. Exercise capacity was the only significant predictor of these events in the model.

Patients who stop an exercise test because of dyspnea probably have exercise-induced left ventricular dysfunction, Dr. Deedwania said. In elderly patients with diabetes, coronary disease often does not manifest as chest pain, but rather as heart failure symptoms, he noted.

Dr. Aronow had no financial disclosures for his study.

Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment.

Source DR. ARONOW

ORLANDO — In elderly patients with diabetes and no history of coronary artery or peripheral artery disease, exercise capacity less than 85% of predicted independently identified patients at increased risk for death, stroke, or myocardial infarction in a study of more than 600 patients.

“This is the first study in patients with diabetes and without known coronary artery disease” to show that functional capacity predicts outcome, Dr. Wilbert S. Aronow said at the annual scientific sessions of the American Heart Association.

The finding suggests more aggressive use of a treadmill exercise sestamibi stress test (TESST) to screen patients with diabetes, especially as they get older. “Zero in on these patients; they are at greater risk,” said Dr. Aronow, a cardiologist at New York Medical College in Valhalla. Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment by lipid-lowering drugs and blood pressure control, regardless of the extent of their vascular disease.

“Especially in elderly patients with long-duration diabetes, the [management] approach should focus on blood pressure and on lowering low-density lipoprotein cholesterol,” commented Dr. Prakash C. Deedwania, professor of medicine and chief of cardiology at the University of California, San Francisco, in Fresno.

The study included 609 consecutive patients with diabetes and no history of coronary artery disease, peripheral artery disease, pulmonary disease, or diabetic neuropathy. Their average age was 70 years. All patients underwent a TESST, the duration of which was limited by dyspnea in all cases; none of the patients had chest pain during the exercise test.

Dr. Aronow and his associates calculated the percentage of predicted exercise each person achieved based on their age and sex. A peak exercise level less than 85% of predicted occurred in 301 patients (49%), and a level of 85% or greater occurred in the other 308 (51%). The two subgroups had similar profiles for age, sex, race, smoking prevalence, hypertension, dyslipidemia, body mass index, renal function, duration of diabetes, and use of insulin, aspirin, statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers. In all, 241 of the patients also underwent coronary angiography, including 128 patients from the low exercise–capacity group and 113 from the group with a level of 85% or greater.

Angiography revealed multivessel obstructive coronary disease in 38% of the low exercise–capacity patients and in 18% of the higher exercise–capacity patients, a statistically significant difference.

After an average follow-up of 47 months, low exercise–capacity patients had a mortality rate of 10%, and a combined rate of death, myocardial infarction, or stroke of 21%. In contrast, the higher exercise–capacity patients had a mortality rate of 4% and a combined event rate of 12%, statistically significant differences between the two subgroups.

A multivariate analysis that controlled for 20 baseline variables showed that patients with an exercise capacity of 85% or greater had a significant 48% reduced risk for death, myocardial infarction, or stroke, compared with the other group. Exercise capacity was the only significant predictor of these events in the model.

Patients who stop an exercise test because of dyspnea probably have exercise-induced left ventricular dysfunction, Dr. Deedwania said. In elderly patients with diabetes, coronary disease often does not manifest as chest pain, but rather as heart failure symptoms, he noted.

Dr. Aronow had no financial disclosures for his study.

Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment.

Source DR. ARONOW

ORLANDO — In elderly patients with diabetes and no history of coronary artery or peripheral artery disease, exercise capacity less than 85% of predicted independently identified patients at increased risk for death, stroke, or myocardial infarction in a study of more than 600 patients.

“This is the first study in patients with diabetes and without known coronary artery disease” to show that functional capacity predicts outcome, Dr. Wilbert S. Aronow said at the annual scientific sessions of the American Heart Association.

The finding suggests more aggressive use of a treadmill exercise sestamibi stress test (TESST) to screen patients with diabetes, especially as they get older. “Zero in on these patients; they are at greater risk,” said Dr. Aronow, a cardiologist at New York Medical College in Valhalla. Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment by lipid-lowering drugs and blood pressure control, regardless of the extent of their vascular disease.

“Especially in elderly patients with long-duration diabetes, the [management] approach should focus on blood pressure and on lowering low-density lipoprotein cholesterol,” commented Dr. Prakash C. Deedwania, professor of medicine and chief of cardiology at the University of California, San Francisco, in Fresno.

The study included 609 consecutive patients with diabetes and no history of coronary artery disease, peripheral artery disease, pulmonary disease, or diabetic neuropathy. Their average age was 70 years. All patients underwent a TESST, the duration of which was limited by dyspnea in all cases; none of the patients had chest pain during the exercise test.

Dr. Aronow and his associates calculated the percentage of predicted exercise each person achieved based on their age and sex. A peak exercise level less than 85% of predicted occurred in 301 patients (49%), and a level of 85% or greater occurred in the other 308 (51%). The two subgroups had similar profiles for age, sex, race, smoking prevalence, hypertension, dyslipidemia, body mass index, renal function, duration of diabetes, and use of insulin, aspirin, statins, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers. In all, 241 of the patients also underwent coronary angiography, including 128 patients from the low exercise–capacity group and 113 from the group with a level of 85% or greater.

Angiography revealed multivessel obstructive coronary disease in 38% of the low exercise–capacity patients and in 18% of the higher exercise–capacity patients, a statistically significant difference.

After an average follow-up of 47 months, low exercise–capacity patients had a mortality rate of 10%, and a combined rate of death, myocardial infarction, or stroke of 21%. In contrast, the higher exercise–capacity patients had a mortality rate of 4% and a combined event rate of 12%, statistically significant differences between the two subgroups.

A multivariate analysis that controlled for 20 baseline variables showed that patients with an exercise capacity of 85% or greater had a significant 48% reduced risk for death, myocardial infarction, or stroke, compared with the other group. Exercise capacity was the only significant predictor of these events in the model.

Patients who stop an exercise test because of dyspnea probably have exercise-induced left ventricular dysfunction, Dr. Deedwania said. In elderly patients with diabetes, coronary disease often does not manifest as chest pain, but rather as heart failure symptoms, he noted.

Dr. Aronow had no financial disclosures for his study.

Older patients with diabetes who show poor exercise capacity on a TESST need aggressive treatment.

Source DR. ARONOW

PHILADELPHIA — Electronic health records improve patient care, streamline record keeping, and substantially boost practice efficiency, agreed three rheumatologists who have switched from paper to electrons.

“I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40 patients a day,” Dr. Charles King commented during an electronic health record forum at the annual meeting of the American College of Rheumatology.

Other benefits from adopting electronic health records (EHRs) are that “our data are clearly better, our work flow is certainly better, we have improved communication within our system, and we can more easily do research,” added Dr. King, senior rheumatologist at North Mississippi Medical Clinics in Tupelo.

Dr. King chairs the ACR's Committee on Rheumatologic Care's health information technology subcommittee, and organized the forum.

But physicians must realize that starting up an EHR system also has significant disadvantages: an expensive up front cost, a large learning curve, loss of face time with patients, and privacy issues that the system must be designed to address.

Data entry during the physical examination is the most challenging part of EHR” record keeping, and as a result he still handles that aspect by dictation.

Dr. King also warned that entering impressions and management plans into a patient's record can end up as simply a list rather than more insightful thoughts.

“We cannot lose the thinking style of rheumatology” when using EHR, he warned.

Start-up problems can be so daunting that Dr. King, as well as his colleagues at the forum, recommended that practices build their EHRs in stages.

Another speaker at the forum, Dr. Craig Carson, documented the improved efficiency that came with the introduction of EHR into his practice at the Oklahoma Arthritis Center in Edmond.

During the third year that his three-physician practice had an EHR system in place, they had a $123,000 boost to their income, the result of being able to nearly double the number of patients seen per day.

Dr. Carson reported going from an average of 18 patients per day to 28, and his partners had even more expansion. But this benefit was balanced by a first-year start-up cost of more than $257,000.

“The cost is considerable, but it leads to rewards,” said Dr. Carson, who also serves on the ACR's health information technology subcommittee.

The start up was also an ordeal. “You need someone [in the practice] who decides that 'no matter what, we'll stick with [EHR]' because it is not easy. You'll have employees who say they can't do it and want to quit. You need to get through that. Once you do, everyone will be happy,” Dr. Carson said.

Another subcommittee member who spoke, Dr. Thomas Geppert, had his own list of benefits that have come from adopting EHRs.

They included improved quality of care because of better access to patient data, availability of computerized prescribing, an easy system for generating reminders, the potential to incorporate rules that minimize mistakes, and easy access to patient records from anywhere.

Other benefits have been better work flow organization, a need for less office staff, and improved communication with patients.

Like his colleagues, Dr. Geppert, a physician at Rheumatology Associates in Dallas and another member of the ACR's subcommittee dealing with health information technology, also cited the disadvantages of cost, the potential for system failure, and the ordeal of getting a system in place, and recommended introducing a new EHR system in stages.

Disclosures: Dr. King, Dr. Carson, and Dr. Geppert all said that they had no financial relationships to disclose.

'I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40' a day.

Source DR. KING

PHILADELPHIA — Electronic health records improve patient care, streamline record keeping, and substantially boost practice efficiency, agreed three rheumatologists who have switched from paper to electrons.

“I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40 patients a day,” Dr. Charles King commented during an electronic health record forum at the annual meeting of the American College of Rheumatology.

Other benefits from adopting electronic health records (EHRs) are that “our data are clearly better, our work flow is certainly better, we have improved communication within our system, and we can more easily do research,” added Dr. King, senior rheumatologist at North Mississippi Medical Clinics in Tupelo.

Dr. King chairs the ACR's Committee on Rheumatologic Care's health information technology subcommittee, and organized the forum.

But physicians must realize that starting up an EHR system also has significant disadvantages: an expensive up front cost, a large learning curve, loss of face time with patients, and privacy issues that the system must be designed to address.

Data entry during the physical examination is the most challenging part of EHR” record keeping, and as a result he still handles that aspect by dictation.

Dr. King also warned that entering impressions and management plans into a patient's record can end up as simply a list rather than more insightful thoughts.

“We cannot lose the thinking style of rheumatology” when using EHR, he warned.

Start-up problems can be so daunting that Dr. King, as well as his colleagues at the forum, recommended that practices build their EHRs in stages.

Another speaker at the forum, Dr. Craig Carson, documented the improved efficiency that came with the introduction of EHR into his practice at the Oklahoma Arthritis Center in Edmond.

During the third year that his three-physician practice had an EHR system in place, they had a $123,000 boost to their income, the result of being able to nearly double the number of patients seen per day.

Dr. Carson reported going from an average of 18 patients per day to 28, and his partners had even more expansion. But this benefit was balanced by a first-year start-up cost of more than $257,000.

“The cost is considerable, but it leads to rewards,” said Dr. Carson, who also serves on the ACR's health information technology subcommittee.

The start up was also an ordeal. “You need someone [in the practice] who decides that 'no matter what, we'll stick with [EHR]' because it is not easy. You'll have employees who say they can't do it and want to quit. You need to get through that. Once you do, everyone will be happy,” Dr. Carson said.

Another subcommittee member who spoke, Dr. Thomas Geppert, had his own list of benefits that have come from adopting EHRs.

They included improved quality of care because of better access to patient data, availability of computerized prescribing, an easy system for generating reminders, the potential to incorporate rules that minimize mistakes, and easy access to patient records from anywhere.

Other benefits have been better work flow organization, a need for less office staff, and improved communication with patients.

Like his colleagues, Dr. Geppert, a physician at Rheumatology Associates in Dallas and another member of the ACR's subcommittee dealing with health information technology, also cited the disadvantages of cost, the potential for system failure, and the ordeal of getting a system in place, and recommended introducing a new EHR system in stages.

Disclosures: Dr. King, Dr. Carson, and Dr. Geppert all said that they had no financial relationships to disclose.

'I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40' a day.

Source DR. KING

PHILADELPHIA — Electronic health records improve patient care, streamline record keeping, and substantially boost practice efficiency, agreed three rheumatologists who have switched from paper to electrons.

“I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40 patients a day,” Dr. Charles King commented during an electronic health record forum at the annual meeting of the American College of Rheumatology.

Other benefits from adopting electronic health records (EHRs) are that “our data are clearly better, our work flow is certainly better, we have improved communication within our system, and we can more easily do research,” added Dr. King, senior rheumatologist at North Mississippi Medical Clinics in Tupelo.

Dr. King chairs the ACR's Committee on Rheumatologic Care's health information technology subcommittee, and organized the forum.

But physicians must realize that starting up an EHR system also has significant disadvantages: an expensive up front cost, a large learning curve, loss of face time with patients, and privacy issues that the system must be designed to address.

Data entry during the physical examination is the most challenging part of EHR” record keeping, and as a result he still handles that aspect by dictation.

Dr. King also warned that entering impressions and management plans into a patient's record can end up as simply a list rather than more insightful thoughts.

“We cannot lose the thinking style of rheumatology” when using EHR, he warned.

Start-up problems can be so daunting that Dr. King, as well as his colleagues at the forum, recommended that practices build their EHRs in stages.

Another speaker at the forum, Dr. Craig Carson, documented the improved efficiency that came with the introduction of EHR into his practice at the Oklahoma Arthritis Center in Edmond.

During the third year that his three-physician practice had an EHR system in place, they had a $123,000 boost to their income, the result of being able to nearly double the number of patients seen per day.

Dr. Carson reported going from an average of 18 patients per day to 28, and his partners had even more expansion. But this benefit was balanced by a first-year start-up cost of more than $257,000.

“The cost is considerable, but it leads to rewards,” said Dr. Carson, who also serves on the ACR's health information technology subcommittee.

The start up was also an ordeal. “You need someone [in the practice] who decides that 'no matter what, we'll stick with [EHR]' because it is not easy. You'll have employees who say they can't do it and want to quit. You need to get through that. Once you do, everyone will be happy,” Dr. Carson said.

Another subcommittee member who spoke, Dr. Thomas Geppert, had his own list of benefits that have come from adopting EHRs.

They included improved quality of care because of better access to patient data, availability of computerized prescribing, an easy system for generating reminders, the potential to incorporate rules that minimize mistakes, and easy access to patient records from anywhere.

Other benefits have been better work flow organization, a need for less office staff, and improved communication with patients.

Like his colleagues, Dr. Geppert, a physician at Rheumatology Associates in Dallas and another member of the ACR's subcommittee dealing with health information technology, also cited the disadvantages of cost, the potential for system failure, and the ordeal of getting a system in place, and recommended introducing a new EHR system in stages.

Disclosures: Dr. King, Dr. Carson, and Dr. Geppert all said that they had no financial relationships to disclose.

'I have gone from seeing 25 patients a day [before switching to electronic health records] to seeing 40' a day.

Source DR. KING

PHILADELPHIA — Patients with moderately active rheumatoid arthritis had a high prevalence of vitamin D insufficiency and deficiency in a prospective study of 1,160 patients in the Veterans Health Administration system.

Based on this finding, the “testing of vitamin D levels is mandatory” in patients with RA, Dr. Gail S. Kerr said at the annual meeting of the American College of Rheumatology.

In addition, although “more evidence is needed to determine the exact role of vitamin D in patients with rheumatoid arthritis, we advocate vitamin D replacement as an additional, non-DMARD [disease-modifying antirheumatic drug] component of RA management,” said Dr. Kerr, chief of rheumatology at the Washington D.C. VA Medical Center.

The study used patients who were enrolled in the U.S. VARA (Veterans With RA) registry, which began in 2002 at eight VHA centers around the United States. The registry protocol included drawing a blood specimen from patients at the time of their enrollment. Patients entered the registry at similar rates throughout the year, which meant that no seasonal bias skewed their vitamin D levels.

The VHA provides medical care to more than 67,000 people with RA. Investigators plan to expand the registry to enroll 12,000 patients eventually.

The current analysis focused on the 1,160 enrolled patients for whom vitamin D levels were available. Measurement of serum vitamin D was by a radioimmunoassay. Insufficiency was defined as a level of 30 ng/mL or lower; deficiency was 20 ng/mL or lower.

Patients' average age was 64 years; 91% were men, 77% were white, and 17% were black. Their average duration of RA was 12 years, and they generally had moderately active disease. Their average body mass index was 28 kg/m

Low vitamin D levels were common, with 85% of the patients meeting the definition of insufficiency, and 45% with a deficient level.

The average vitamin D level for the entire group was 22 ng/mL.

A multivariate analysis showed that patients who were younger and not white, as well as those with higher tender joint counts and higher body mass index, had a higher risk for having vitamin D insufficiency or deficiency.

Low vitamin D levels were also significantly linked with being positive for anti–cyclic citrullinated protein antibodies, and with a higher number of comorbidities, Dr. Kerr concluded.

PHILADELPHIA — Patients with moderately active rheumatoid arthritis had a high prevalence of vitamin D insufficiency and deficiency in a prospective study of 1,160 patients in the Veterans Health Administration system.

Based on this finding, the “testing of vitamin D levels is mandatory” in patients with RA, Dr. Gail S. Kerr said at the annual meeting of the American College of Rheumatology.

In addition, although “more evidence is needed to determine the exact role of vitamin D in patients with rheumatoid arthritis, we advocate vitamin D replacement as an additional, non-DMARD [disease-modifying antirheumatic drug] component of RA management,” said Dr. Kerr, chief of rheumatology at the Washington D.C. VA Medical Center.

The study used patients who were enrolled in the U.S. VARA (Veterans With RA) registry, which began in 2002 at eight VHA centers around the United States. The registry protocol included drawing a blood specimen from patients at the time of their enrollment. Patients entered the registry at similar rates throughout the year, which meant that no seasonal bias skewed their vitamin D levels.

The VHA provides medical care to more than 67,000 people with RA. Investigators plan to expand the registry to enroll 12,000 patients eventually.

The current analysis focused on the 1,160 enrolled patients for whom vitamin D levels were available. Measurement of serum vitamin D was by a radioimmunoassay. Insufficiency was defined as a level of 30 ng/mL or lower; deficiency was 20 ng/mL or lower.

Patients' average age was 64 years; 91% were men, 77% were white, and 17% were black. Their average duration of RA was 12 years, and they generally had moderately active disease. Their average body mass index was 28 kg/m

Low vitamin D levels were common, with 85% of the patients meeting the definition of insufficiency, and 45% with a deficient level.

The average vitamin D level for the entire group was 22 ng/mL.

A multivariate analysis showed that patients who were younger and not white, as well as those with higher tender joint counts and higher body mass index, had a higher risk for having vitamin D insufficiency or deficiency.

Low vitamin D levels were also significantly linked with being positive for anti–cyclic citrullinated protein antibodies, and with a higher number of comorbidities, Dr. Kerr concluded.

PHILADELPHIA — Patients with moderately active rheumatoid arthritis had a high prevalence of vitamin D insufficiency and deficiency in a prospective study of 1,160 patients in the Veterans Health Administration system.

Based on this finding, the “testing of vitamin D levels is mandatory” in patients with RA, Dr. Gail S. Kerr said at the annual meeting of the American College of Rheumatology.

In addition, although “more evidence is needed to determine the exact role of vitamin D in patients with rheumatoid arthritis, we advocate vitamin D replacement as an additional, non-DMARD [disease-modifying antirheumatic drug] component of RA management,” said Dr. Kerr, chief of rheumatology at the Washington D.C. VA Medical Center.

The study used patients who were enrolled in the U.S. VARA (Veterans With RA) registry, which began in 2002 at eight VHA centers around the United States. The registry protocol included drawing a blood specimen from patients at the time of their enrollment. Patients entered the registry at similar rates throughout the year, which meant that no seasonal bias skewed their vitamin D levels.

The VHA provides medical care to more than 67,000 people with RA. Investigators plan to expand the registry to enroll 12,000 patients eventually.

The current analysis focused on the 1,160 enrolled patients for whom vitamin D levels were available. Measurement of serum vitamin D was by a radioimmunoassay. Insufficiency was defined as a level of 30 ng/mL or lower; deficiency was 20 ng/mL or lower.

Patients' average age was 64 years; 91% were men, 77% were white, and 17% were black. Their average duration of RA was 12 years, and they generally had moderately active disease. Their average body mass index was 28 kg/m

Low vitamin D levels were common, with 85% of the patients meeting the definition of insufficiency, and 45% with a deficient level.

The average vitamin D level for the entire group was 22 ng/mL.

A multivariate analysis showed that patients who were younger and not white, as well as those with higher tender joint counts and higher body mass index, had a higher risk for having vitamin D insufficiency or deficiency.

Low vitamin D levels were also significantly linked with being positive for anti–cyclic citrullinated protein antibodies, and with a higher number of comorbidities, Dr. Kerr concluded.

PHILADELPHIA — Using MRI to help classify spondyloarthritis poses a significant risk for error, according to findings from a multicenter study that evaluated 85 MRI scans.

A panel of five rheumatologists and radiologists specially trained in MRI assessment of lesions associated with spondyloarthritis (SpA) in the sacroiliac joint misclassified 6 of 85 cases based on their MRI scans, Dr. Ulrich Weber said at the annual meeting of the American College of Rheumatology.

The finding underscores the importance of establishing reliable thresholds for diagnosing significant SpA-associated pathology in MRI scans of sacroiliac joints, said Dr. Weber, a rheumatologist at the Balgrist University Clinic in Zurich, Switzerland. “MRI will never be 100% accurate for confirming a diagnosis of SpA. Low-grade active and chronic abnormalities [on MRI] are seen in up to a third of healthy volunteers and patients with non-specific back pain.”

The findings, “underscore the limitations of reading MRI, even in the hands of trained readers,” commented Dr. John D. Reveille, professor of internal medicine and director of the division of rheumatology and clinical immunogenetics at the University of Texas Medical School at Houston.

Although sacroiliitis identified by plain radiography has been the traditional method for classifying SpA, MRI has been increasingly used. MRI's role for classifying SpA solidified in 2009 with the publication of the SpA classification criteria of the Assessment of Spondyloarthritis International Society (ASAS) (Ann Rheum Dis. 2009;68:777-83). In this paper, ASAS said that MRI scans showing “active (acute) inflammation of sacroiliac joints … highly suggestive of sacroiliitis associated with SpA” could substitute for radiographic evidence when classifying a patient as having SpA.

To examine the consequences of MRI assessment, Dr. Weber and his associates developed a training program to teach rheumatologists and radiologists to identify sacroiliac joint pathology indicative of SpA. The classification criteria focused on four features of active inflammation: bone marrow edema, erosion, fatty infiltration, and ankylosis. They then had a panel of two radiologists and three rheumatologists who underwent training review MRI scans from 59 asymptomatic healthy volunteers and 26 patients with nonspecific back pain of mechanical origin. All subjects were age 45 years or younger.

Among the 59 healthy volunteers, one or more of the panel members misclassified four (7%) as having MRI features indicative of SpA. When reviewing the 26 patients with mechanically induced lower back pain, panel members misclassified two (8%) as having SpA.

The error rate was even higher for some of the individual assessment elements. At least two panel members identified some degree of bone marrow edema in 22% of the healthy volunteers and in 38% of the patients with nonspecific, mechanical back pain.

Two panel members scored the bone marrow edema clinically relevant in 12% of the healthy volunteers and in 23% of the patients with mechanically triggered back pain.

Roughly similar mistake rates occurred when the panelists scored the MRIs for bone erosions and for fatty infiltrations.

The physicians who read MRI scans of back pain patients need careful training and clear guidance on what constitutes SpA lesions in sacroiliac joints, accordng to Dr. Weber.

Disclosures: Dr. Weber said that he and his associates had no financial disclosures relevant to his presentation on SpA and MRI.

'MRI will never be 100% accurate for confirming a diagnosis of SpA.'

Source DR. WEBER

My Take

Knowing How to Use MRI Is Key

I would agree that the isolated use of an MRI evaluation of the sacroiliac joint would be subject to false-positive error for the diagnosis of ankylosing spondylitis. The value of the MRI findings needs to be used in combination with the other features that are seen with AS, which is why the diagnosis is based upon multiple criteria. Nevertheless, in conjunction with other findings the ability to recognize inflammation of the sacroiliac joint in particular with negative radiographs has been well reported to improve the diagnostic yield significantly.

I would agree that an experienced radiologist needs to interpret the significance of the MRI findings as is evidenced by Dr. Ulrich Weber's findings. The false positives reported may well have been avoided in experienced radiologist's hands. In fact, sensitivity of MRI is always an issue. That does not mean it is a bad tool. Like driving a race car, you have to know how to handle and interpret the high tech equipment you are utilizing.

NORMAN B. GAYLIS, M.D., president of the International Society of Extremity MRI in Rheumatology, is in private practice in Aventura, Fla. He has written and lectured widely on in-office use of imaging in rheumatology. Dr. Gaylis reports financial relationships with numerous pharmaceutical companies.

DR. GAYLI

PHILADELPHIA — Using MRI to help classify spondyloarthritis poses a significant risk for error, according to findings from a multicenter study that evaluated 85 MRI scans.

A panel of five rheumatologists and radiologists specially trained in MRI assessment of lesions associated with spondyloarthritis (SpA) in the sacroiliac joint misclassified 6 of 85 cases based on their MRI scans, Dr. Ulrich Weber said at the annual meeting of the American College of Rheumatology.

The finding underscores the importance of establishing reliable thresholds for diagnosing significant SpA-associated pathology in MRI scans of sacroiliac joints, said Dr. Weber, a rheumatologist at the Balgrist University Clinic in Zurich, Switzerland. “MRI will never be 100% accurate for confirming a diagnosis of SpA. Low-grade active and chronic abnormalities [on MRI] are seen in up to a third of healthy volunteers and patients with non-specific back pain.”

The findings, “underscore the limitations of reading MRI, even in the hands of trained readers,” commented Dr. John D. Reveille, professor of internal medicine and director of the division of rheumatology and clinical immunogenetics at the University of Texas Medical School at Houston.

Although sacroiliitis identified by plain radiography has been the traditional method for classifying SpA, MRI has been increasingly used. MRI's role for classifying SpA solidified in 2009 with the publication of the SpA classification criteria of the Assessment of Spondyloarthritis International Society (ASAS) (Ann Rheum Dis. 2009;68:777-83). In this paper, ASAS said that MRI scans showing “active (acute) inflammation of sacroiliac joints … highly suggestive of sacroiliitis associated with SpA” could substitute for radiographic evidence when classifying a patient as having SpA.

To examine the consequences of MRI assessment, Dr. Weber and his associates developed a training program to teach rheumatologists and radiologists to identify sacroiliac joint pathology indicative of SpA. The classification criteria focused on four features of active inflammation: bone marrow edema, erosion, fatty infiltration, and ankylosis. They then had a panel of two radiologists and three rheumatologists who underwent training review MRI scans from 59 asymptomatic healthy volunteers and 26 patients with nonspecific back pain of mechanical origin. All subjects were age 45 years or younger.

Among the 59 healthy volunteers, one or more of the panel members misclassified four (7%) as having MRI features indicative of SpA. When reviewing the 26 patients with mechanically induced lower back pain, panel members misclassified two (8%) as having SpA.

The error rate was even higher for some of the individual assessment elements. At least two panel members identified some degree of bone marrow edema in 22% of the healthy volunteers and in 38% of the patients with nonspecific, mechanical back pain.

Two panel members scored the bone marrow edema clinically relevant in 12% of the healthy volunteers and in 23% of the patients with mechanically triggered back pain.

Roughly similar mistake rates occurred when the panelists scored the MRIs for bone erosions and for fatty infiltrations.

The physicians who read MRI scans of back pain patients need careful training and clear guidance on what constitutes SpA lesions in sacroiliac joints, accordng to Dr. Weber.

Disclosures: Dr. Weber said that he and his associates had no financial disclosures relevant to his presentation on SpA and MRI.

'MRI will never be 100% accurate for confirming a diagnosis of SpA.'

Source DR. WEBER

My Take

Knowing How to Use MRI Is Key

I would agree that the isolated use of an MRI evaluation of the sacroiliac joint would be subject to false-positive error for the diagnosis of ankylosing spondylitis. The value of the MRI findings needs to be used in combination with the other features that are seen with AS, which is why the diagnosis is based upon multiple criteria. Nevertheless, in conjunction with other findings the ability to recognize inflammation of the sacroiliac joint in particular with negative radiographs has been well reported to improve the diagnostic yield significantly.

I would agree that an experienced radiologist needs to interpret the significance of the MRI findings as is evidenced by Dr. Ulrich Weber's findings. The false positives reported may well have been avoided in experienced radiologist's hands. In fact, sensitivity of MRI is always an issue. That does not mean it is a bad tool. Like driving a race car, you have to know how to handle and interpret the high tech equipment you are utilizing.

NORMAN B. GAYLIS, M.D., president of the International Society of Extremity MRI in Rheumatology, is in private practice in Aventura, Fla. He has written and lectured widely on in-office use of imaging in rheumatology. Dr. Gaylis reports financial relationships with numerous pharmaceutical companies.

DR. GAYLI

PHILADELPHIA — Using MRI to help classify spondyloarthritis poses a significant risk for error, according to findings from a multicenter study that evaluated 85 MRI scans.

A panel of five rheumatologists and radiologists specially trained in MRI assessment of lesions associated with spondyloarthritis (SpA) in the sacroiliac joint misclassified 6 of 85 cases based on their MRI scans, Dr. Ulrich Weber said at the annual meeting of the American College of Rheumatology.

The finding underscores the importance of establishing reliable thresholds for diagnosing significant SpA-associated pathology in MRI scans of sacroiliac joints, said Dr. Weber, a rheumatologist at the Balgrist University Clinic in Zurich, Switzerland. “MRI will never be 100% accurate for confirming a diagnosis of SpA. Low-grade active and chronic abnormalities [on MRI] are seen in up to a third of healthy volunteers and patients with non-specific back pain.”

The findings, “underscore the limitations of reading MRI, even in the hands of trained readers,” commented Dr. John D. Reveille, professor of internal medicine and director of the division of rheumatology and clinical immunogenetics at the University of Texas Medical School at Houston.

Although sacroiliitis identified by plain radiography has been the traditional method for classifying SpA, MRI has been increasingly used. MRI's role for classifying SpA solidified in 2009 with the publication of the SpA classification criteria of the Assessment of Spondyloarthritis International Society (ASAS) (Ann Rheum Dis. 2009;68:777-83). In this paper, ASAS said that MRI scans showing “active (acute) inflammation of sacroiliac joints … highly suggestive of sacroiliitis associated with SpA” could substitute for radiographic evidence when classifying a patient as having SpA.

To examine the consequences of MRI assessment, Dr. Weber and his associates developed a training program to teach rheumatologists and radiologists to identify sacroiliac joint pathology indicative of SpA. The classification criteria focused on four features of active inflammation: bone marrow edema, erosion, fatty infiltration, and ankylosis. They then had a panel of two radiologists and three rheumatologists who underwent training review MRI scans from 59 asymptomatic healthy volunteers and 26 patients with nonspecific back pain of mechanical origin. All subjects were age 45 years or younger.

Among the 59 healthy volunteers, one or more of the panel members misclassified four (7%) as having MRI features indicative of SpA. When reviewing the 26 patients with mechanically induced lower back pain, panel members misclassified two (8%) as having SpA.

The error rate was even higher for some of the individual assessment elements. At least two panel members identified some degree of bone marrow edema in 22% of the healthy volunteers and in 38% of the patients with nonspecific, mechanical back pain.

Two panel members scored the bone marrow edema clinically relevant in 12% of the healthy volunteers and in 23% of the patients with mechanically triggered back pain.

Roughly similar mistake rates occurred when the panelists scored the MRIs for bone erosions and for fatty infiltrations.

The physicians who read MRI scans of back pain patients need careful training and clear guidance on what constitutes SpA lesions in sacroiliac joints, accordng to Dr. Weber.

Disclosures: Dr. Weber said that he and his associates had no financial disclosures relevant to his presentation on SpA and MRI.

'MRI will never be 100% accurate for confirming a diagnosis of SpA.'

Source DR. WEBER

My Take

Knowing How to Use MRI Is Key

I would agree that the isolated use of an MRI evaluation of the sacroiliac joint would be subject to false-positive error for the diagnosis of ankylosing spondylitis. The value of the MRI findings needs to be used in combination with the other features that are seen with AS, which is why the diagnosis is based upon multiple criteria. Nevertheless, in conjunction with other findings the ability to recognize inflammation of the sacroiliac joint in particular with negative radiographs has been well reported to improve the diagnostic yield significantly.

I would agree that an experienced radiologist needs to interpret the significance of the MRI findings as is evidenced by Dr. Ulrich Weber's findings. The false positives reported may well have been avoided in experienced radiologist's hands. In fact, sensitivity of MRI is always an issue. That does not mean it is a bad tool. Like driving a race car, you have to know how to handle and interpret the high tech equipment you are utilizing.

NORMAN B. GAYLIS, M.D., president of the International Society of Extremity MRI in Rheumatology, is in private practice in Aventura, Fla. He has written and lectured widely on in-office use of imaging in rheumatology. Dr. Gaylis reports financial relationships with numerous pharmaceutical companies.

DR. GAYLI

PHILADELPHIA — Vaccination rates in patients with rheumatoid arthritis and other rheumatic diseases continued to lag behind recommendations in two reports at the annual meeting of the American College of Rheumatology.

Although the Centers for Disease Control and Prevention and other infectious disease organizations recommend annual influenza vaccination and current pneumonia vaccination for all adults with chronic illness, including rheumatoid arthritis and other rheumatic diseases, both studies found vaccination rates of roughly 50%.

One report, by researchers from the CDC, used data collected in 2007 by the Behavioral Risk Factor Surveillance System, which conducted more than 400,000 random telephone surveys of U.S. adults. The researchers identified respondents as having arthritis if they had ever been told by a doctor that they had arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Among the survey respondents who self-identified as having arthritis, 52% reported receiving an influenza vaccination by either injection or nasal spray in the prior 12 months; the flu vaccination rate was 31% in the other adults surveyed, Jennifer Hootman, Ph.D., and her colleague reported in a poster at the meeting.

In an analysis that adjusted for demographics and general health indicators, people with arthritis were 40% more likely to have had an influenza vaccination, compared with the other adults surveyed, said Dr. Hootman, a CDC epidemiologist.

Several factors correlated with the prevalence of vaccination among the people with arthritis. Age was a particularly strong factor, even though influenza vaccination is recommended for all adults with a chronic illness like arthritis regardless of their age. People who self-reported arthritis and were aged 65 years or older were more than fourfold as likely to have had flu vaccination as were those aged 18-44 years. People with arthritis who were aged 45-64 years were about 60% more likely to have received vaccine, compared with the younger adults.

Another significant determinant in people with arthritis were state of residence. Arthritis patients living in South Carolina had a vaccination prevalence lower than 40%, and arthritis patients living in Arkansas, Indianapolis, and Texas had a rate of 40%-45%. Racial and ethnic minorities, smokers, people who were obese, and people with a low education level also had a significantly lower vaccination rate than did people with arthritis in comparator groups, Dr. Hootman reported in her poster.

The second report looked at rates of vaccination for influenza, pneumonia, and herpes zoster during 2007-2008 among 10,481 patients with arthritis who were enrolled in the National Data Bank for Rheumatic Diseases.

The study population included patients with rheumatoid arthritis (70%), fibromyalgia (10%), systemic lupus erythematosus (8%), and noninflammatory rheumatic diseases (12%). Health authorities also recommend regular pneumococcal vaccination for adults with a chronic disease such as arthritis, but no recommendation exists for the herpes zoster vaccine.

The results again showed that vaccination rates for influenza and pneumonia were very age dependent. Patients reported influenza vaccination during the prior year at a rate of 41% in those aged younger than 40 years, 56% in those aged 40-64 years, and 70% in those aged 65 or older, said Kalab Michaud, Ph.D., a rheumatology researcher at the University of Nebraska in Omaha.

The rates for ever having a pneumococcal vaccination were 30% in patients younger than 40 years, 45% in those aged 45-64, and 78% in patients 65 or older. The rates for a pneumococcal vaccination within the prior 5 years were 24%, 37%, and 66% respectively in the three age groups.

Patients aged 65 years or older also reported a 9% rate of ever having vaccination for herpes zoster.

The vaccination rates for both influenza and pneumonia were significantly higher in patients with lupus, and higher for pneumonia in patients with rheumatoid arthritis, compared with patients with noninflammatory rheumatoid disease. The immunization rates for both infections were significantly lower in patients with fibromyalgia.

Other significant determinants of vaccination rates in these patients included an education level lower than high school graduation, which reduced the rate, and the presence of comorbidities such as diabetes, heart disease, or pulmonary disease, which increased the rate.

The researchers on both studies reported no financial disclosures.

Influenza vaccination rates were 41% (younger than age 40), 56% (40-64), and 70% (65 or older).

Source DR. MICHAUD

PHILADELPHIA — Vaccination rates in patients with rheumatoid arthritis and other rheumatic diseases continued to lag behind recommendations in two reports at the annual meeting of the American College of Rheumatology.

Although the Centers for Disease Control and Prevention and other infectious disease organizations recommend annual influenza vaccination and current pneumonia vaccination for all adults with chronic illness, including rheumatoid arthritis and other rheumatic diseases, both studies found vaccination rates of roughly 50%.

One report, by researchers from the CDC, used data collected in 2007 by the Behavioral Risk Factor Surveillance System, which conducted more than 400,000 random telephone surveys of U.S. adults. The researchers identified respondents as having arthritis if they had ever been told by a doctor that they had arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Among the survey respondents who self-identified as having arthritis, 52% reported receiving an influenza vaccination by either injection or nasal spray in the prior 12 months; the flu vaccination rate was 31% in the other adults surveyed, Jennifer Hootman, Ph.D., and her colleague reported in a poster at the meeting.

In an analysis that adjusted for demographics and general health indicators, people with arthritis were 40% more likely to have had an influenza vaccination, compared with the other adults surveyed, said Dr. Hootman, a CDC epidemiologist.

Several factors correlated with the prevalence of vaccination among the people with arthritis. Age was a particularly strong factor, even though influenza vaccination is recommended for all adults with a chronic illness like arthritis regardless of their age. People who self-reported arthritis and were aged 65 years or older were more than fourfold as likely to have had flu vaccination as were those aged 18-44 years. People with arthritis who were aged 45-64 years were about 60% more likely to have received vaccine, compared with the younger adults.

Another significant determinant in people with arthritis were state of residence. Arthritis patients living in South Carolina had a vaccination prevalence lower than 40%, and arthritis patients living in Arkansas, Indianapolis, and Texas had a rate of 40%-45%. Racial and ethnic minorities, smokers, people who were obese, and people with a low education level also had a significantly lower vaccination rate than did people with arthritis in comparator groups, Dr. Hootman reported in her poster.

The second report looked at rates of vaccination for influenza, pneumonia, and herpes zoster during 2007-2008 among 10,481 patients with arthritis who were enrolled in the National Data Bank for Rheumatic Diseases.

The study population included patients with rheumatoid arthritis (70%), fibromyalgia (10%), systemic lupus erythematosus (8%), and noninflammatory rheumatic diseases (12%). Health authorities also recommend regular pneumococcal vaccination for adults with a chronic disease such as arthritis, but no recommendation exists for the herpes zoster vaccine.

The results again showed that vaccination rates for influenza and pneumonia were very age dependent. Patients reported influenza vaccination during the prior year at a rate of 41% in those aged younger than 40 years, 56% in those aged 40-64 years, and 70% in those aged 65 or older, said Kalab Michaud, Ph.D., a rheumatology researcher at the University of Nebraska in Omaha.

The rates for ever having a pneumococcal vaccination were 30% in patients younger than 40 years, 45% in those aged 45-64, and 78% in patients 65 or older. The rates for a pneumococcal vaccination within the prior 5 years were 24%, 37%, and 66% respectively in the three age groups.

Patients aged 65 years or older also reported a 9% rate of ever having vaccination for herpes zoster.

The vaccination rates for both influenza and pneumonia were significantly higher in patients with lupus, and higher for pneumonia in patients with rheumatoid arthritis, compared with patients with noninflammatory rheumatoid disease. The immunization rates for both infections were significantly lower in patients with fibromyalgia.

Other significant determinants of vaccination rates in these patients included an education level lower than high school graduation, which reduced the rate, and the presence of comorbidities such as diabetes, heart disease, or pulmonary disease, which increased the rate.

The researchers on both studies reported no financial disclosures.

Influenza vaccination rates were 41% (younger than age 40), 56% (40-64), and 70% (65 or older).

Source DR. MICHAUD

PHILADELPHIA — Vaccination rates in patients with rheumatoid arthritis and other rheumatic diseases continued to lag behind recommendations in two reports at the annual meeting of the American College of Rheumatology.

Although the Centers for Disease Control and Prevention and other infectious disease organizations recommend annual influenza vaccination and current pneumonia vaccination for all adults with chronic illness, including rheumatoid arthritis and other rheumatic diseases, both studies found vaccination rates of roughly 50%.

One report, by researchers from the CDC, used data collected in 2007 by the Behavioral Risk Factor Surveillance System, which conducted more than 400,000 random telephone surveys of U.S. adults. The researchers identified respondents as having arthritis if they had ever been told by a doctor that they had arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Among the survey respondents who self-identified as having arthritis, 52% reported receiving an influenza vaccination by either injection or nasal spray in the prior 12 months; the flu vaccination rate was 31% in the other adults surveyed, Jennifer Hootman, Ph.D., and her colleague reported in a poster at the meeting.

In an analysis that adjusted for demographics and general health indicators, people with arthritis were 40% more likely to have had an influenza vaccination, compared with the other adults surveyed, said Dr. Hootman, a CDC epidemiologist.

Several factors correlated with the prevalence of vaccination among the people with arthritis. Age was a particularly strong factor, even though influenza vaccination is recommended for all adults with a chronic illness like arthritis regardless of their age. People who self-reported arthritis and were aged 65 years or older were more than fourfold as likely to have had flu vaccination as were those aged 18-44 years. People with arthritis who were aged 45-64 years were about 60% more likely to have received vaccine, compared with the younger adults.

Another significant determinant in people with arthritis were state of residence. Arthritis patients living in South Carolina had a vaccination prevalence lower than 40%, and arthritis patients living in Arkansas, Indianapolis, and Texas had a rate of 40%-45%. Racial and ethnic minorities, smokers, people who were obese, and people with a low education level also had a significantly lower vaccination rate than did people with arthritis in comparator groups, Dr. Hootman reported in her poster.

The second report looked at rates of vaccination for influenza, pneumonia, and herpes zoster during 2007-2008 among 10,481 patients with arthritis who were enrolled in the National Data Bank for Rheumatic Diseases.

The study population included patients with rheumatoid arthritis (70%), fibromyalgia (10%), systemic lupus erythematosus (8%), and noninflammatory rheumatic diseases (12%). Health authorities also recommend regular pneumococcal vaccination for adults with a chronic disease such as arthritis, but no recommendation exists for the herpes zoster vaccine.

The results again showed that vaccination rates for influenza and pneumonia were very age dependent. Patients reported influenza vaccination during the prior year at a rate of 41% in those aged younger than 40 years, 56% in those aged 40-64 years, and 70% in those aged 65 or older, said Kalab Michaud, Ph.D., a rheumatology researcher at the University of Nebraska in Omaha.

The rates for ever having a pneumococcal vaccination were 30% in patients younger than 40 years, 45% in those aged 45-64, and 78% in patients 65 or older. The rates for a pneumococcal vaccination within the prior 5 years were 24%, 37%, and 66% respectively in the three age groups.

Patients aged 65 years or older also reported a 9% rate of ever having vaccination for herpes zoster.

The vaccination rates for both influenza and pneumonia were significantly higher in patients with lupus, and higher for pneumonia in patients with rheumatoid arthritis, compared with patients with noninflammatory rheumatoid disease. The immunization rates for both infections were significantly lower in patients with fibromyalgia.

Other significant determinants of vaccination rates in these patients included an education level lower than high school graduation, which reduced the rate, and the presence of comorbidities such as diabetes, heart disease, or pulmonary disease, which increased the rate.

The researchers on both studies reported no financial disclosures.

Influenza vaccination rates were 41% (younger than age 40), 56% (40-64), and 70% (65 or older).

Source DR. MICHAUD

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53).

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, reported Ms. Crowson in a poster. She is a biostatistician at the Mayo Clinic. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use on people older than 74 years, Ms. Crowson and her associates applied the same analysis to 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%. The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients.”

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS, an idea explored in a poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5-year follow-up, 66 patients had acute coronary syndrome events.

To enhance the FRS predictive power, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster reviewed the ability of methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%-20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: All of the study investigators and their associates reported having no relevant financial relationships.

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53).

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, reported Ms. Crowson in a poster. She is a biostatistician at the Mayo Clinic. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use on people older than 74 years, Ms. Crowson and her associates applied the same analysis to 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%. The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients.”

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS, an idea explored in a poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5-year follow-up, 66 patients had acute coronary syndrome events.

To enhance the FRS predictive power, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster reviewed the ability of methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%-20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: All of the study investigators and their associates reported having no relevant financial relationships.

PHILADELPHIA — The Framingham risk score does a poor job of estimating future risk for cardiovascular events in patients with rheumatoid arthritis, according to a review of 550 unselected patients drawn from the general population.

Results from a second study reported at the annual meeting of the American College of Rheumatology suggested that adding three more risk markers (carotid disease assessment with ultrasound, erythrocyte sedimentation rate, and cumulative steroid dose) to the standard Framingham risk score (FRS) could significantly improve prognostic accuracy for coronary disease in patients with RA. And findings from a third study presented at the meeting indicated that treatment with methotrexate is an effective way to cut coronary disease risk in RA patients.

To assess the prognostic value of the FRS, Cynthia S. Crowson and her associates at the Mayo Clinic in Rochester, Minn., used data collected for the Rochester Epidemiology Project from residents of Olmsted County, Minn. They included 550 people who presented during 1988-2008 with incident RA that matched the 1987 RA criteria of the American College of Rheumatology and who also had no history of cardiovascular disease at the time of their initial RA diagnosis. The researchers calculated an FRS for each of these patients based on their medical records and using a revised FRS (introduced in 2008) that predicted risk for cardiovascular disease events including stroke and peripheral artery disease as well as coronary disease (Circulation 2008;117:743-53).

The Mayo researchers then compared the predicted rate of cardiovascular disease events against the actual rate observed during the first 10 years following RA diagnosis. The study group included 491 RA patients who were aged 30-74 years, and 59 others who were aged 75 years or older. The FRS is designed for application to adults younger than 75.

Among the 341 women aged 30-74 years, the average predicted event rate was 5%, and the actual observed rate was 11%. Among the 150 men in this age range, the predicted rate was 12% and the observed rate was 26%, reported Ms. Crowson in a poster. She is a biostatistician at the Mayo Clinic. The researchers used a regression model to calculate a standard incidence ratio, in which the ratio of actual to expected events was 79% in women and 56% in men. Both differences were statistically significant. Further analysis showed that the largest differences between observed and expected rates were in women aged 55 years or older and in men aged 45 or older.

Although the FRS is not designed for use on people older than 74 years, Ms. Crowson and her associates applied the same analysis to 59 RA patients in this age group. The results again showed a significant excess of observed events over expected events. In women, the observed event rate was 57%, compared with an expected 14% rate. In men, the observed rate was 87%, compared with an expected rate of 37%. The findings “underscore the need for [a more] accurate tool to predict the risk of cardiovascular disease in RA patients.”

One way to improve cardiovascular risk assessment in RA patients may be to add additional risk factors to the FRS, an idea explored in a poster presented by Dr. Inmaculada del Rincon, a rheumatologist at the University of Texas Health Sciences Center in San Antonio, and her associates. They compared the correlation between standard FRS assessment and an enhanced assessment model for predicting the risk of acute coronary syndrome events in 599 RA patients. None of the patients in the study had a history of cardiovascular disease at the time the study began. During an average 5-year follow-up, 66 patients had acute coronary syndrome events.

To enhance the FRS predictive power, they added measures of carotid plaque and intima-media thickness by carotid ultrasonography, erythrocyte sedimentation rate, and cumulative glucocorticoid dose. The analysis showed that the standard FRS accounted for 70% of the events observed in the patients. The three additional risk markers boosted this rate to 76%, a statistically significant improvement, reported Dr. del Rincon and her associates in their poster.

A third poster reviewed the ability of methotrexate to reduce cardiovascular risk in RA patients. Dr. Janice Gupta, a rheumatologist at Tufts Medical Center in Boston, and her associates reviewed the medical literature for studies that compared the ability of methotrexate to lower cardiovascular events against other RA treatments. They identified six studies published during 2002-2007 that made this comparison. The studies involved a total of about 162,000 RA patients. The results showed a consistent pattern of reduced cardiovascular events in the patients who received methotrexate. The event risk was generally reduced by 15%-20%, compared with other RA treatments; the researchers did not calculate an overall summary risk-reduction rate.

Disclosures: All of the study investigators and their associates reported having no relevant financial relationships.