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People taking the acid reflux drugs Prilosec or Protonix in combination with blood thinners such as Plavix have a higher risk for death after angioplasty than people who don’t take the two popular antacids, a new study has found.

The people in the study, which is to be presented Monday at the American Heart Association’s annual meeting in Orlando, Fla., were undergoing what doctors call “percutaneous coronary intervention,” or PCI, a common procedure used to widen a narrowed artery. PCI typically involves balloon angioplasty followed by the insertion of a drug-emitting stent, a tiny mesh tube, to keep the vessel open.

Study author Dr. Joseph Sweeny, an assistant professor of medicine at Mount Sinai Medical Center in New York City, said that the clinical implications for users of these reflux drugs — called proton pump inhibitors (PPIs)– remain unclear.

“It’s a moving target,” Sweeny said, adding that, “although certain confounders are going to be at play that do cause limitations of the study, in my opinion the data speaks for itself. We found an overall increased mortality in this patient population that takes a PPI with clopidogrel [Plavix]. The problem was I was not able to look at specific cause of mortality.”

One expert agreed that the study, while interesting, does not prove cause-and-effect.

“All this shows is that people taking PPIs have a worse outcome than those not taking PPIs,” said Dr. Chet Rihal, director of the Mayo Clinic’s catheterization lab in Rochester, Minn. “This does not prove there’s causation. That would be like saying that carrying matches is associated with lung cancer. It is associated, but it doesn’t mean it causes lung cancer.”

“These data do not show that patients should stop taking PPIS, and, in fact, it would be dangerous for patients to stop PPIs or other medication without a physician’s advice,” Rihal said.

The mortality increase shown by the study is not surprising, he added. “People who are older are the ones who get stents and tend to get ulcers and stomach problems [warranting use of PPIs] so we would expect them to have a worse prognosis,” Rihal said. “Whether it’s due to medical problems or whether it has something to do with a drug-drug reaction is unclear.”

PPIs are frequently given with aspirin and Plavix after an angioplasty procedure to reduce the chances of gastrointestinal bleeding. Many people also take PPIs for various gastrointestinal conditions, including acid reflux, gastric ulcers and stomach bleeding.

For the study, Sweeny and colleagues looked back at records of more than 8,300 people who underwent the procedure between April 2003 and June 2007. They were followed for an average of two years.

During the study period, 17 percent of them took a PPI. All of the patients also took both aspirin and Plavix, the researchers said.

Overall, people taking a PPI had a 30 percent higher risk for dying after their PCI procedure than did people who were not taking a PPI. Two drugs in the class appeared to contribute most of the added risk: Omeprazole (Prilosec) was associated with 72 percent higher risk for death after PCI, and pantoprazole (Protonix) was linked to a 54 percent increased risk, the study found.

Two other common PPIs — esomeprazole (Nexium) and lansoprazole (Prevacid) — did not show a heightened risk. There wasn’t enough data to rank a fifth drug, Aciphex (raberprazole), according to the study.

Sweeny could not say why Nexium and Prevacid were exempt from the effect. “It’s a very heterogenous interaction and depends on how a specific population metabolizes that drug,” he said.

People taking PPIs along with a blood thinner also had a small risk for developing blood clots after insertion of a stent, the team found.

The findings add to a lively back-and-forth about the dangers — or lack thereof — of combining antacids with blood thinners, with studies over the past few years coming down on both sides of the debate.

But according to Rihal, there may actually be an answer to this question, though not from the current study. He pointed to an earlier study that demonstrated an interaction between the two types of drugs, but only in a test tube.

When it came to replicating those findings in humans, however, no extra problems showed up in people taking PPIs compared with those not taking them. This was later confirmed by another study, Rihal said.

“That was actually the best-done study of them all,” he said.

One problem with the Mount Sinai study, Rihal said, is that it does not indicate why people were taking the antacids.

PPIs, used by millions of Americans, have also been linked to a number of other health risks, including an increase in hip fractures, diarrhea and community-acquired pneumonia.

Former American Heart Association (AHA) president and current spokesman Dr. Sidney Smith said that new AHA/American College of Cardiology recommendations regarding PPIs would be announced Wednesday at the Orlando conference.

While overall care of heart attack patients in the United States is good, gaps remain in the treatment of patients 80 and older, a new study suggests.

Researchers analyzed 2000-2009 data on 156,677 heart attack patients treated at 416 centers enrolled in the American Heart Association’s “Get With the Guidelines — Coronary Artery Disease” program.

The analysis revealed that 86 percent of patients aged 80 and older received early beta blocker therapy, compared with 90 percent of patients aged 64 or younger. Only 43 percent of patients 80 and older received balloon angioplasty within 90 minutes of hospital arrival, compared with 54 percent of younger patients.

Older patients had a far higher rate of in-hospital deaths (11.8 percent vs. 2.4 percent) and were less likely than younger ones to be taking statins when discharged from hospital (76 percent vs. 92 percent).

Co-existing health conditions were more common in the older patients than in the younger patients, noted Dr. Gregg C. Fonarow of the University of California, Los Angeles Medical Center and colleagues.

The study, to be presented Monday at the American Heart Association’s annual meeting in Orlando, Fla., shows there is room to improve care and outcomes in older heart attack patients, the researchers said.

A new, inexpensive screening method could help reduce the risk for sudden cardiac death among high school athletes, U.S. researchers report.

Athletic trainers at 10 high schools in Houston used a laptop system to perform electrocardiograms (EKGs) on 2,057 student athletes. The results, which were transmitted to a cardiologist, revealed 186 athletes with abnormal EKGs. All but 13 of them received subsequent echocardiograms.

Among the findings:
Three students had serious cardiac conditions, including right ventricular cardiomyopathy, which is abnormal enlargement, thickening or stiffening of heart muscle; coarctation, a narrowing, of the aorta; and non-compaction cardiomyopathy, a rare genetic condition caused by failure of myocardial development during embryo development.
Eight students had Wolff-Parkinson-White syndrome, an electrical defect that can cause arrhythmia. They were referred to pediatricians.
Mitral valve prolapse was detected in 17 students, and six were diagnosed with pulmonary hypertension.
Two students were found to have bicuspid aortic valves, and six had mild to moderate vascular regurgitation.
Three students with hypertension had concentric left ventricular hypertension and were referred for treatment.
Eleven students were told they could not participate in competitive athletics.

Performing EKGs in schools would cost less than $5 per student, and the EKG laptop equipment could be provided to school districts for about $500, according to Dr. Thomas DeBauche, of Cypress Cardiology in Houston.

Though school-based EKG screening would not eliminate sudden cardiac death among high school athletes, it could significantly reduce the risk, the researchers said.

The study was to be presented Sunday at the American Heart Association’s annual meeting, in Orlando, Fla.

Examining the metabolism of embryos may help determine which ones offer the best chance of success with in vitro fertilization (IVF), a new study finds.

Currently, the process of selecting embryos for implantation in the mother’s womb is highly subjective.

“It’s a guessing game that can end in IVF failure or multiple pregnancies,” Dr. Emre Seli, an associate professor in the obstetrics, gynecology and reproductive sciences department at Yale School of Medicine, said in a school news release. “Our goal is to find a way to pinpoint the embryos with the best chance of success, so that we can transfer fewer embryos and cut down on the possibility of multiple pregnancies without reducing the pregnancy rate.”

Seli and colleagues have studied the metabolomic profiles of spent embryo cultures. A metabolomic profile is a unique chemical signature of the activity of embryos in culture.

The Yale team found that a viability score based on a noninvasive metabolomic assessment of embryo culture media affected pregnancy outcomes in women treated at four centers in Europe and Australia. The research, performed in collaboration with Molecular Biometrics Inc., was presented this week at the American Society for Reproductive Medicine annual meeting, in Atlanta.

“These findings have important implications for the more than 125,000 IVF cycles performed yearly in the United States,” Seli said. “The high multiple pregnancy rates associated with IVF have significant public health consequences, such as decreased survival and increased risk of lifelong disability associated with severe prematurity.”

Dying white cancer patients are more likely than black patients to have their end-of-life wishes respected, a new U.S. study shows.

Some black patients who asked not to be resuscitated or put on a ventilator received the treatment anyway and died in an intensive care unit, said the researchers. White patients who voiced a wish for aggressive care were three times more likely to receive it than black patients who had expressed the same desire.

“We’re not saying that black treatment preferences were ignored. Black patients did want, and did receive, more aggressive care than whites. The disparity was in the effect of treatment preferences on care received — not that black preferences didn’t matter,” senior author Holly Prigerson, of the Dana-Farber Cancer Institute in Boston, said in a news release from the institute.

The study included 234 white and 68 black patients with advanced cancer. They were interviewed at the start of the study and monitored until their death, which occurred an average of 3.5 months later.

“None of the white patients who reported the completion of a do-not-resuscitate order, or a DNR order, at baseline subsequently received intensive care in the last week of life. This did not prove to be the case for black patients. DNR orders did not significantly protect black patients from intensive end-of-life care in this study,” Prigerson said.

This disparity may be because of disruptions in continuity of care for black patients and cultural differences that hindered patient-doctor communication. The findings highlight the need for better communication between black cancer patients and their cancer care providers.

Breast-feeding is a great time to bond with your little one. But for some moms, it can be a painful experience.

The Nemours Foundation offers these suggestions to help make breast-feeding a little more comfortable:
Make sure your baby is latched on correctly.
Some women benefit from nursing more often, but for a shorter spans.
Offer baby the side that’s less sore.
Try an over-the-counter lotion just for breast-feeding moms.
Rub a bit of breast milk on the nipple after the feeding, and let it air dry.
Breast-feed in different positions to help drain all areas of the breast.
Use an ice pack or a warm compress on the breast just before nursing.

Doctors should prescribe oral phosphodiesterase type 5 (PDE-5) inhibitor drugs, such as Viagra, Cialis and Levitra, for men with erectile dysfunction, unless the patient is on nitrate therapy, according to a clinical practice guideline issued by the American College of Physicians.

The type of erectile dysfunction (ED) drug prescribed should be based on the individual preferences of patients, including cost of medication, ease of use and types of side effects, the authors noted.

“The evidence is insufficient to compare the effectiveness or adverse effects of different PDE-5 inhibitors for the treatment of ED because there were only a few head-to-head trials,” guideline lead author Dr. Amir Qaseem, senior medical associate with the ACP, said in a news release.

Qaseem and colleagues analyzed the findings of 130 studies that evaluated PDE-5 inhibitors alone or combined. They found that treatment with the drugs led to statistically significant and clinically relevant improvements in sexual intercourse and erectile function in men with ED, regardless of the cause (e.g., diabetes, depression, prostate cancer) or ED severity at the start of the study.

Overall, PDE-5 inhibitors were relatively well-tolerated and associated with only mild or moderate side effects, such as headaches, flushing, upset stomach and runny nose, the authors found.

The guideline is published in the Oct. 20 issue of the journal Annals of Internal Medicine.

Because there is no conclusive evidence about the effectiveness of hormonal blood tests or treatment in patients with low testosterone levels, the ACP doesn’t recommend for or against routine use of the tests in ED patients. The college says doctors should make decisions to measure hormone levels based on an individual patient’s clinical symptoms (decreased libido, premature ejaculation, fatigue, etc.) and physical signs (such as testicular or muscle atrophy) that suggest hormone problems.

Localities that ban smoking in bars, restaurants and other public places witness a quick drop in heart attacks, two new studies show.

The research — which incorporated data from a total of 24 studies of smoking bans across the country — found at least a 17 percent reduction in heart attacks one year after the bans had been enacted.

“That’s when you lump all these studies together,” said Dr. David G. Meyers, a professor of cardiology and preventive medicine at the University of Kansas and lead author of a report that will appear in the Sept. 29 issue of the Journal of the American College of Cardiology.

“One thing we looked at was the effect of duration,” Meyers said. “The longer the study, the greater the beneficial effect. On average, after one year there was a 25 percent reduction in the risk of heart attack. The risk reduction got bigger the longer the ban was in effect.”

The other study, published in the Sept. 21 issue of Circulation, found a 17 percent drop in heart attack rates after one year and about a 36 percent drop three years after smoking restrictions had been enacted.

It incorporated data from 13 studies in the United States, Canada and Europe. Meyers’s research effort analyzed data from 11 studies of 10 public smoking bans in the same geographic regions.

Meyers said that the greatest benefit revealed in his study was seen in people younger than 50. Women seemed to benefit more than men, but for an unknown reason, he said.

Because the studies his group reviewed included localities with a total population of 22 million, “we can make a rather firm conclusion that smoking bans reduce the risk of heart attacks,” Meyers said.

The results indicate that a nationwide ban on smoking in public places would prevent 156,400 heart attacks a year in the United States, the report in the cardiology journal said.

One scenario in particular appears to clinch the case, Meyers said. When officials in Butte, Mont., banned smoking in public places, the incidence of heart attacks decreased by 45 percent. A judge reversed the banning ordinance, and the incidence of heart attacks returned to the previous level, he said.

Smoking increases the risk of heart attacks and other cardiovascular problems in a number of ways — by making artery-clogging blood clots more common, by reducing the amount of beneficial HDL cholesterol and by raising the possibility of dangerous heart rhythm abnormalities. Smokers double their risk for heart attacks, and secondhand smoke exposure increases the risk by 30 percent, the researchers said.

Smoking bans almost certainly decrease the risks for cardiovascular problems such as stroke and lung disorders such as emphysema, as well as lung cancer, said Dr. Steven A. Schroeder, director of the Smoking Cessation Leadership Center at the University of California, San Francisco, “but those decreases generally take a lot longer to take place.” He wrote an editorial that accompanied the publication of Meyers’s study.

Predictions that smoking bans will cause a disastrous drop in business for bars and restaurants generally don’t come through, Schroeder said. “A lot of people don’t like going into smoking restaurants and bars,” he said. “The last haven of smoking is in gambling casinos.”

And though many gamblers might not mind a smoky atmosphere, employees are inevitably exposed to the dangers of smoke, Schroeder said. A similar situation was faced by airline flight attendants in the 1970s and 1980s, he said. They eventually sued the airlines and won a settlement that has enabled them to establish a research institute on the dangers of smoking, Schroeder said.

New York City, which has had a smoking ban for several years, now proposes to extend that ban to city parks. Meyers said that seems like a good idea, though the immediate effect is uncertain.

“The dilutional effect of open air means there might not be enough smoke to make a difference,” he said. “But only a tiny exposure to cigarette smoke can be dangerous. I would like to see everyone stop smoking, and I think a smoking ban in parks would help, but there is no scientific evidence to show that it would help.”

Statins could be as beneficial for people with acceptable cholesterol readings but high levels of inflammation as they are for those with high cholesterol levels, a new analysis finds.

An earlier study of more than 17,000 participants, known as the JUPITER trial, found that rosuvastatin (Crestor) cut the risk for serious vascular problems in people whose cholesterol levels were not high while high-sensitivity C-reactive protein (hs-CRP) levels were.

CRP is a protein that increases during whole-body inflammation, and testing its levels has become an additional way to assess the risk of cardiovascular disease.

“The JUPITER trial demonstrated that rosuvastatin, when given to apparently healthy men and women with low cholesterol but increased hs-CRP, reduced heart attack by 55 percent, stroke by 48 percent, angioplasty and bypass surgery by 46 percent and all-cause mortality by 20 percent — all highly significant — and did so in the absence of major side effects,” said Dr. Paul Ridker, director of the Center for Cardiovascular Disease Prevention at Brigham and Women’s Hospital in Boston and a member of the JUPITER Study Group. He is the lead author of the new analysis, which is published online Sept. 22 and in the November issue of Circulation: Cardiology Quality and Outcomes.

The new analysis takes the study results a step further, attempting to interpret them in practical terms — to evaluate whether the absolute risk reduction justifies wider prescribing of the statins.

Ridker and his colleagues calculated the absolute risk reduction and also used an epidemiological measure called “number needed to treat.” That measure looks at the number of people who would need to be treated to prevent one additional bad outcome.

The JUPITER participants all had acceptable LDL cholesterol (below 130 milligrams per deciliter) but an hs-CRP of 2 milligrams/liter or higher. According to the American Heart Association, an hs-CRP of less than 1 reflects a low risk of getting cardiovascular disease.

The researchers found that “the efficiency of treating elevated hs-CRP patients with statins is at least as good, if not better, than the efficiency of treating those with high cholesterol,” Ridker said.

The new analysis, he said, is expected to help clarify future guidelines about who should and should not be on statins.

JUPITER was funded by AstraZeneca, which makes Crestor.

And though the analysis was meant to help physicians and policymakers, it does have a take-home message for patients, one expert said.

It suggests there is a much broader population that may benefit from statins, said Dr. Gregg Fonarow, a cardiologist and professor of medicine at the University of California, Los Angeles. “Those who tend to be treated those who have very high cholesterol.”

Also, he said, some doctors test their patients who at risk for cardiovascular disease for CRP levels, but other do not. “You might want to ask your doctor if you should have a CRP test,” Fonarow said.

To assess cardiovascular risk, a doctor takes many factors into account, including age, blood pressure, cholesterol and family history — and the use of statins doesn’t negate the need for paying attention to lifestyle issues, Ridker and Fonarow agreed. They stressed the need to maintain a healthy weight and healthy cholesterol levels, to exercise regularly and to not smoke, or to stop if you do.

And not everyone should take statins, Fonarow added. People with active liver disease, for instance, should not be on the medications, he said, nor should those who have had an adverse reaction to them.

New research suggests that people who have successfully lost weight will activate certain parts of their brains when confronted with images of food.

While preliminary, the findings indicate that those who shed pounds — and keep them off — tap into regions of the brain related to control over urges.

“It may be that they actually recruit new brain regions to help with their weight loss,” said study author Jeanne McCaffery, an assistant professor of psychiatry and human behavior at Brown Medical School, in Providence, R.I.

McCaffery and her colleagues wanted to understand how people react to “food cues” — in this case, photos of food. “People make decisions about whether or not they’re going to eat food, and that decision-making usually comes when they first smell or see the food,” she said.

The researchers recruited several groups of participants: 18 people of normal weight, 16 fat people and 17 people who had successfully shed weight — at least 30 pounds from their maximum weight — and kept it off for at least three years.

The participants underwent brain scans as they looked at pictures of high-calorie and low-calorie foods. The MRI scans revealed that those who had successfully lost weight showed more activity in the parts of the brain that are associated with inhibition and in dealing with complex tasks, McCaffery said.

Those of normal weight didn’t show this pattern. This may be because “they’ve been of normal weight all of their lifetime. The successful weight losers have to put in more effort to avoid eating foods or to control their response to food.”

The findings appear in the October issue of the American Journal of Clinical Nutrition.

Ian McDonald, a professor of metabolic physiology who wrote a commentary accompanying the study, said questions remain.

For one, did the people who lost weight begin to have this brain response when they started shedding pounds or later? “Similarly, are the obese different from the non-obese because of an intrinsic difference or as a result of the inappropriate eating which has led to their obesity?” asked McDonald, a researcher at the University of Nottingham Medical School in England.

In other words, does inappropriate eating by heavy people lead to differences in the way their brains work when they look at food?

Also, McDonald said, future research needs to figure out what the differences in brain activity mean for the choices people make. “Similar measurements need to be made before, during and after weight loss,” he noted.

For now, McCaffery said the researchers would like to understand better how the brain works in people who have lost weight successfully.

In the future, she said, it’s possible that “we’ll be able to teach other people how to do that.”