ADA AHA ACC一起發表aspirin 對於DM病人CV primary prevention的建議

我們有很多risk evaluation的工具，像framinghan cv risk, UKPDS risk

那10年risk > 10%的人就值得吃，算起來這些人就是：
=>男性>50，女性>60，且有一個額外risk factor(smoking,HTN,dyslipidemia,FHx of premature CVD, albuminuria)

10年risk <5% 不該吃
=> 男性不到50，女性不到60，沒有risk factor

那10年risk 5-10%的
=>可吃可不吃

但是就算三巨頭這麼說，還有兩個study可以提供更好的證據


Aspirin for Primary Prevention in Patients with Diabetes

Recommendations from three professional organizations

The American Heart Association, the American College of Cardiology, and the American Diabetes Association have collaborated to produce a position statement on aspirin for primary prevention in patients with diabetes. The statement includes a meta-analysis of nine randomized trials, in which aspirin lowered risk for coronary events by 9% and for stroke by 15%; neither difference reached statistical significance. The authors estimate that excess risk for gastrointestinal bleeding conferred by aspirin could be as high as 1 to 5 episodes per 1000 diabetic patients annually. Based on their balancing of benefits and harms, the authors make the following recommendations for primary prevention in adults with diabetes:

* Low-dose aspirin (75–162 mg daily) "is reasonable" for patients with 10-year cardiovascular disease (CVD) risk >10% and no risk factors for bleeding. This group would include most diabetic men older than 50 and women older than 60 who have at least one additional major risk factor (i.e., smoking, hypertension, dyslipidemia, family history of premature CVD, or albuminuria).
* Aspirin "should not be recommended" for diabetic men younger than 50 and women younger than 60 with no other risk factors (10-year CVD risk, <5%).
* Aspirin "might be considered" for those at intermediate risk (10-year CVD risk, 5%–10%); this group would include younger patients with, and older patients without, other risk factors.

Several websites with calculators to estimate 10-year cardiovascular risk are listed, including the UKPDS Risk Engine and the ARIC CHD Risk Calculator.

Comment: The authors acknowledge that their recommendations are based on inconclusive evidence: Event rates in randomized trials have been too low to generate precise estimates of aspirin's effect, some estimates are drawn from potentially biased subgroup analyses, and the incremental benefit of aspirin in patients who take statins and other risk-lowering agents is unclear. Ongoing trials that will provide additional data on aspirin prophylaxis include ACCEPT-D (from Italy) and ASCEND (from the U.K.).

— Allan S. Brett, MD

This position statement was published concurrently in Diabetes Care 2010; 33:1395 and J Am Coll Cardiol 2010; 55:2878.

Published in Journal Watch General Medicine July 8, 2010
Citation(s):

Pignone M et al. Aspirin for primary prevention of cardiovascular events in people with diabetes: A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation. Circulation 2010 Jun 22; 121:2694. (http://dx.doi.org/10.1161/CIR.0b013e3181e3b133)

* Original article (Subscription may be required)
* Medline abstract (Free)


https://docs.google.com/fileview?id=0B278nGJMQBk7NmY2NTRjZTUtN2Y1Ni00NWY3LWI2ODAtZmZlMWU1MjVmODUw&hl=zh_TW

http://docs.google.com/present/edit?id=0AW78nGJMQBk7ZGc1d3FjYmpfMjMyZHBjaHN3ZnA&hl=zh_TW

留言

張貼留言

這個網誌中的熱門文章

即便是用IGRA, 有時也要等大於三個月才能決定TB contact

圖片
接觸TB後，TST大抵上2-12週轉陽，IGRA大抵上6-10週，但IGRA可以長到3個月以上 TB Tests Can Have a Lengthy Window Period Two studies suggest that interferon- release assay conversion sometimes occurs more than 3 months after exposure to active tuberculosis. Increasingly, interferon- release assays (IGRAs) are being used for diagnosing latent tuberculosis (TB). Although the tuberculin skin test (TST) traditionally used for this purpose converts to positive within 2 to 12 weeks after an individual is exposed to someone with active TB, the interval for IGRA conversion has remained unclear. Current guidelines recommend repeating an initially negative IGRA after 6 to 10 weeks, but this recommendation is not based on controlled studies. Two recent investigations address this issue. Anibarro and colleagues conducted a longitudinal prospective analysis among contacts of TB patients in Spain. The 152 contacts received a TST and an IGRA at first visit; for individuals with negative or conflicting results, t
閱讀完整內容

白宮為了掌控醫療費用，傾向大型醫療，個體戶勢必受挫

所以一旦政府介入，中外醫療提供者都傾向大型化…… independent practice -> dreaming 診所評鑑??應該擋住! http://www.medscape.com/viewarticle/727420 Physicians Say White House Should Not Write Off Small Practices August 24, 2010 — In a newly published article, the White House is advising physicians to accept a life in Big Medicine — as a hospital employee or member of a large group practice — in the wake of healthcare reform. Some leaders of organized medicine, however, are objecting to the government message. "We're not ready to write off the small practices," J. Fred Ralston Jr, MD, president of the American College of Physicians, told Medscape Medical News. "We think there needs to be more than one delivery model." "America is not a one-size-fits-all country," added M. Todd Williamson, MD, a neurologist from Lawrenceville, Georgia, and spokesperson for a coalition of medical societies opposed to the new healthcare reform law, now called the Affordable Care Act. Dr. Ralston and Dr.
閱讀完整內容

老美接受LTBI treatment的人，不到一半完治，和duration成正比

This study shows that although acceptance of LTBI treatment is relatively high (83%), the proportion completing is low (47%). When the product of these two proportions is calculated, we see that completion was achieved by only 39% of persons who were offered LTBI treatment. The major risk factor for noncompletion was being prescribed the 9-month INH regimen. As shown in Figure 1, when the proportions completing the three most commonly prescribed regimens are compared, it can be seen that there is an inverse relationship between length of the regimen prescribed and the proportion completing treatment. The increased completion that we observed with the 4-month rifampin regimen is consistent with previous reports.[18–20] It is of interest to note that if completion of the 9-month regimen were defined as completion of at least 6 months of INH, the noncompletion rate of the 9-month regimen, 42.9%, would have been almost identical to that of the 6-month regimen, 44.8%. Thus, prescribing the
閱讀完整內容