Statin-Associated Rhabdomyolysis
The risk of rhabdomyolysis is relatively low for the three most frequently prescribed statins—atorvastatin, pravastatin, and simvastatin—but is 10 times higher for cerivastatin, which was taken off the market in August 2001. The risk is more than 5 times higher for fibrates than for statin monotherapy and 12 times higher if the two therapies are combined. Combining cerivastatin with fibrates raises the risk 1,400-fold.
These are some of the conclusions of “the first comprehensive study of rhabdomyolysis incidence associated with statin and fibrate therapy.” The study involved 252,460 patients who began treatment between 1998 and 2001 at 11 medical centers across the United States, reported David J. Graham, M.D., of the Food and Drug Administration, Rockville, Md., and his associates (JAMA 2004;292:2585-90).
Risk increased sharply among older patients and those with diabetes. The number of patients who needed to be treated per year for 1 case of rhabdomyolisis to develop was nearly 228,000 for montherapy with the three major statins, compared with 1 case per 484 for older patients who also had diabetes who took statins plus fibrates, and with 1 case in 10 for patients who took cerivastatin plus fibrates, the researchers said.
Percutaneous PFO Closure After Stroke
Percutaneous closure of a patent foramen ovale is at least as effective as medical therapy in preventing cerebrovascular recurrences among patients whose initial stroke presumably stemmed from the heart condition, according to Stephan Windecker, M.D., and his associates at the University Hospital Bern (Switzerland).
They studied 308 patients treated for cryptogenic stroke that was thought to be related to patent foramen ovale. A total of 158 patients received treatment with standard vitamin K antagonist or antiplatelet medications, while 150 received percutaneous closure with occlusive devices placed under local anesthesia (J. Am. Coll. Cardiol. 2004;44:750-8).
Overall, percutaneous closure was as effective as medication in preventing recurrent TIA or stroke over 4 years of follow-up. The procedure was significantly better in two subgroups of patients: those in whom the intervention induced complete closure of the foramen ovale (event rate of 6.5%, compared with 22.2% for medical therapy) and those who had a history of multiple strokes or TIAs (event rate of 7.3%, compared with 33.2% for medical therapy). This is the first study to compare the percutaneous procedure with medical treatment, and the results indicate that prospective randomized trials are warranted, the investigators said.
Take-Along Pill for Atrial Fibrillation
Patients with occasional atrial fibrillation may eventually be able to treat it by taking a single dose of an antiarrhythmic drug that they carry around with them for that purpose, much as angina patients take nitroglycerin when chest pain arises, according to Paolo Alboni, M.D., of Ospedale Civile, Cento, Italy, and his associates.
The feasibility of this “pill-in-the-pocket” approach was assessed in a study of 210 patients with mild or no heart disease whose AF episodes were infrequent and well-tolerated but lasted long enough to prompt the patients to go to emergency rooms. Over a mean follow-up of 15 months, both flecainide and propafenone interrupted palpitations in 534 of 569 AF episodes (94%), usually within 2 hours. Both drugs were effective for every AF episode in 139 of the 165 patients (84%) who had recurrences (N. Engl. J. Med. 2004;351:2384-91).
The mean number of ER visits for AF among the patients dropped from 45.6 to 4.9 per month, and the mean number of AF-related hospitalizations decreased from 15.0 to 1.6 per month. This approach proved feasible and safe, with a high rate of compliance and a very low incidence of adverse effects, the researchers said.
Biopsy IDs Drug-Induced Myocarditis
For the first time, endomyocardial biopsy was used to identify clozapine-induced hypersensitivity myocarditis in a patient who developed a throat infection, dyspnea, and cardiac enlargement while hospitalized for a schizophrenic break, according to Maurizio Pieroni, M.D., and his associates at San Raffaelel Hospital, Milan.
The 27-year-old man was admitted because resistance to his usual neuroleptic therapy had allowed psychotic symptoms to develop. The patient responded within 12 days to clozapine but on the 12th day developed symptoms that suggested either acute viral myocarditis or a hypersensitivity reaction to the drug. Clozapine-induced myocarditis is often fatal, so clozapine therapy was withdrawn, but it was also the best drug to curb the patient's psychosis (Chest 2004;126:1703-5).
Thus “endomyocardial biopsy was crucial to establish a correct diagnosis and appropriate treatment,” they said.