This Week in the Journal

This Week in the Journal

September 11, 2003

Anticoagulation and Stroke Prevention in Atrial Fibrillation

In a large cohort of patients with nonvalvular atrial fibrillation,oral anticoagulation with warfarin that resulted in an internationalnormalized ratio (INR) of 2.0 or greater not only reduced therisk of ischemic stroke but also reduced its severity and associatedmortality. Less intense anticoagulation (an INR of less than2.0) and aspirin therapy were both less effective. The riskof serious hemorrhage was low until the INR exceeded 3.9.

For stroke prevention, patients with nonvalvular atrial fibrillationshould receive anticoagulant therapy with warfarin with a targetINR of 2.5, unless there are contraindications to anticoagulation.

Related Perspective

Coronary Microvascular Dysfunction in Hypertrophic Cardiomyopathy

Myocardial ischemia due to coronary microvascular dysfunctionis believed to occur in patients with hypertrophic cardiomyopathyand may cause clinical events such as sudden death. In thisstudy, coronary microvascular dysfunction was identified withthe use of positron-emission tomography before and after theinfusion of dipyridamole, a coronary vasodilator. Microvasculardysfunction, defined as an abnormal response to dipyridamole,was associated with an unfavorable outcome, including deathfrom cardiovascular causes.

Related Perspective

Substituting Nonnucleoside Reverse-Transcriptase Inhibitors for Protease Inhibitors in the Treatment of HIV-1

In this randomized study of 460 patients receiving effectivetreatment for human immunodeficiency virus type 1 (HIV-1) disease,nevirapine, efavirenz, or abacavir was substituted for the proteaseinhibitor in a regimen that also included two nucleoside reverse-transcriptaseinhibitors. After 12 months, the increases in CD4 cell countswere similar in the three groups, but there was a trend towarda higher rate of treatment failure in the abacavir group.

The substitution of a nonnucleoside reverse-transcriptase inhibitorfor a protease inhibitor may reduce the rate of adverse effectswhile still suppressing viral replication.

Health, Life Expectancy, and Health Care Spending among the Elderly

Projections of future Medicare expenditures need to take intoaccount the effects of life expectancy and health status onhealth care costs. In this study of Medicare patients, as expected,better health was associated with lower annual costs and longerlives. For persons in better health, the annual savings wereoffset by spending over more years, so that expenditures from70 years of age until death were similar among persons in allinitial health states.

These findings suggest that improvements in health and longevityamong the elderly are unlikely to increase or decrease lifetimeMedicare expenditures substantially.

Related Editorial

Early Alzheimer's Disease

A 72-year-old, college-educated woman comes in for the evaluationof mild memory loss that has been gradually progressing forthe past two years. The patient drives her own car and managesher own finances, although she has recently made some errorsin her checkbook. She also forgot the location of her car ina mall parking lot for two hours. How should this patient beevaluated and treated?

Medical Progress: Sudden Death in Young Athletes

This article summarizes the available information regardingthe cardiac risks of participation in athletics. Hypertrophiccardiomyopathy remains the leading cause of sudden death fromcardiac causes among young athletes. Although controlled studiesare lacking, there is indirect evidence to suggest that screeningand sidelining young athletes with high-risk cardiac findingsare justified and should decrease the number of sudden deathsin this population.

Prevention of Recurrent Preterm Delivery by 17 Alpha-Hydroxyprogesterone Caproate
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Puberty and Genetic Susceptibility to Breast Cancer
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Aromatase Inhibitors in Breast Cancer
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Initial Treatment of Hypertension
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Occupational Exposure to HIV
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Use of Angiography in the Veterans Affairs Health Care System and Medicare
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The Quality of Care in the Veterans Affairs Health Care System
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Repositioning of a Dislocated Intraocular Lens during a Roller-Coaster Ride
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