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Fish consumption and stroke risk in elderly individuals
safety of continued light alcohol consumption among adults who have been able to appropriately regulate the quantity, type and timing of their alcohol use. DM
mined whether insulin sensitizers may improve neuropathic symptoms in addition to glycemic control. DM
Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage
Fish Consumption and Stroke Risk in Elderly Individuals
Kenneth J, Mukamal KJ, Ascherio A, et al. Ann Intern Med 2005;142:11–19.
Mozaffarian D, Longstreth WT, Lemaitre RN, et al. Arch Intern Med 2005;165:200 – 6.
Study Question: The association of light to moderate alcohol consumption with risk for ischemic stroke remains controversial, as do the roles of beverage type and drinking pattern. The objective of the present study was to assess the association of drinking patterns and beverage type with risk for ischemic stroke among men. Methods: This was a prospective cohort study of 38,156 male health professionals who were free of known cardiovascular disease or cancer at baseline. The investigators used a semi-quantitative food-frequency questionnaire to ascertain consumption of regular and light beer, red and white wine, and liquor every 4 years. Alcohol consumption was categorized as light (0.1–9.9 g/d, or ⬍1 drink daily), moderate (10.0 –29.9 g/d, or 1 to 2 drinks daily), and heavier (ⱖ30.0 g/d, or ⱖ3 drinks daily). Results: During a follow-up period of 14 years, 412 cases of incident ischemic stroke were documented. Compared with abstainers, light drinkers had a multivariate-adjusted relative risk of 0.99 (95% CI, 0.72–1.37), moderate drinkers had a multivariate-adjusted relative risk of 1.26 (CI, 0.90 –1.76) and heavier drinkers had a multivariate-adjusted relative risk of 1.42 (CI, 0.97–2.09; p⫽0.01 for trend). Consumption of 10.0 to 29.9 g of alcohol per day 3 to 4 days per week appeared to be associated with the lowest risk (relative risk, 0.68 [CI, 0.44 –1.05]). Red wine consumption was inversely associated with risk in a graded manner (p⫽0.02 for trend), but other beverages were not. The apparently higher risk for ischemic stroke with heavier alcohol use appeared to be most pronounced for the embolic subtype. Conclusions: The researchers concluded that in this sample of male health professionals, light and moderate average alcohol use was generally not associated with an increased risk for ischemic stroke. Intake of more than 2 drinks per day may be associated with a higher risk for ischemic stroke. Perspective: The study suggests that alcohol consumption appears to be associated with a higher risk for ischemic stroke among men who consumed ⬎2 drinks per day, but this association was not apparent at lower levels of intake. A trend toward lower risk for stroke associated with light drinking was most evident for thrombotic stroke and for consumption of 1 to 2 drinks 3 to 4 days per week. Red wine consumption had an inverse association with ischemic stroke, but other alcoholic beverages did not. These findings support current public health recommendations stating that men should consume fewer than 2 drinks per day to help prevent ischemic stroke. The findings also support the
Study Question: Is there a protective effect of fish intake on the risk of strokes? Methods: The association of different types of fish meals with risk of stroke was measured in the Cardiovascular Health Study, a population-based longitudinal cohort study of determinants of cardiovascular events in the elderly. A total of 4775 adults, 65 years or older and free of cerebrovascular disease at baseline during 1989 –1990, underwent an assessment of usual dietary intake using a food-frequency questionnaire. Incident strokes and stroke subtype were prospectively ascertained. Results: Mean age was 72.7 years (range 65–98 years), 44% were male, 22% were diabetic, 45% had hypertension, mean LDL-C was 126 mg/dL, HDL-C 54 mg/dL, and mean internal carotid IMT was 1.6 mm. Fried/fish sandwich and tuna/other fish consumption averaged 0.7 and 2.2 servings per week, respectively. During 12 years of follow-up, 626 incident strokes occurred, including 529 ischemic strokes. In multivariate analyses, tuna/other fish consumption was inversely associated with total stroke (p⫽0.04) and ischemic stroke (p⫽0.02), with 27% lower risk of ischemic stroke with an intake of 1 to 4 times per week (HR, 0.73; 95%CI, 0.55– 0.98) and 30% lower risk with intake of 5 or more times per week (HR, 0.70; 95%CI, 0.50 – 0.99) compared with an intake of less than once per month. In contrast, fried fish/fish sandwich consumption was positively associated with total stroke (p⫽0.006) and ischemic stroke (p⫽0.003), with a 44% higher risk of ischemic stroke with consumption of more than once per week (HR, 1.44; 95%CI, 1.12–1.85) compared with consumption of less than once per month. Fish consumption was not associated with hemorrhagic stroke. Conclusions: Among elderly individuals, consumption of tuna or other broiled or baked fish is associated with lower risk of ischemic stroke, whereas intake of fried fish or fish sandwiches is associated with higher risk. These results suggest that fish consumption may influence stroke risk late in life; potential mechanisms and alternate explanations warrant further study. Perspective: There was no advantage of fish consumption ⬎4 times per week compared to 1 to 4 times. Previous population studies have yielded conflicting results. There are plausible biological mechanisms for beneficial effects of tuna/other fish intake on incidence of stroke, particularly ischemic stroke. In a subset of these patients, consumption of tuna or other broiled or baked fish (r⫽0.35), but not fried fish or fish sandwiches, correlated with plasma phos-
ACC CURRENT JOURNAL REVIEW April 2005
21
pholipid long-chain n-3 fatty acid levels. In experimental studies, n-3 fatty acids from fatty fish influence blood pressure, lipid levels, inflammatory responses, red blood cell deformability, endothelial cell function, and cerebral arteriolar reactivity. This study excluded persons using marine oil supplements, which have been shown to be beneficial postmyocardial infarction. MR
ministered when deferred diagnostic tests confirmed venous thromboembolism. Primary outcome included bleeding risk in persons without confirmed VTE, morbidity and mortality in missed VTE, and accuracy of the clinical protocol. Results: A total of 409 consecutive patients with suspected DVT and 124 with suspected PE were included in the study; 23.8% (95%CI, 20.3–27.3%) of patients had confirmed VTE. At the short-term follow-up (72 h), only a single thromboembolic event (0.2%; upper 95%CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95%CI, 0.2–2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events; 90% of participants were treated as outpatients. Conclusions: In patients with a suspected venous thromboembolism on presentation to an emergency room, treatment with heparin of only those patients with intermediate and high clinical probability who are D-dimer-positive allow for a safe deferral of diagnostic procedures for DVT and PE for up to 72 h. Perspective: The study was carried out in Italy where malpractice liability is considerably different from the U.S. Nevertheless, in the cohort with likely VTE, delaying testing for a few days does not increase the morbidity and mortality significantly in hemodynamically stable patients. MR
Deferment of Objective Assessment of Deep Vein Thrombosis and Pulmonary Embolism Without Increased Risk of Thrombosis Siragusa S, Anastasio R, Porta C, et al. Arch Intern Med 2004;164:2477– 82. Study Question: Can the pretest clinical probability (PCP), positive D-dimer and short-term use of low-molecular weight heparin (LMWH) safely allow a 72-h delay in the definitive evaluation of patients suspected to have deep vein thrombosis (DVT) and pulmonary embolism (PE) (combined as VTE)? Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. All patients were scheduled to undergo objective tests for DVT or PE within 72 h. Standard antithrombotic therapy was ad-
ACC CURRENT JOURNAL REVIEW April 2005
22
mined whether insulin sensitizers may improve neuropathic symptoms in addition to glycemic control. DM
Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage
Fish Consumption and Stroke Risk in Elderly Individuals
Kenneth J, Mukamal KJ, Ascherio A, et al. Ann Intern Med 2005;142:11–19.
Mozaffarian D, Longstreth WT, Lemaitre RN, et al. Arch Intern Med 2005;165:200 – 6.
Study Question: The association of light to moderate alcohol consumption with risk for ischemic stroke remains controversial, as do the roles of beverage type and drinking pattern. The objective of the present study was to assess the association of drinking patterns and beverage type with risk for ischemic stroke among men. Methods: This was a prospective cohort study of 38,156 male health professionals who were free of known cardiovascular disease or cancer at baseline. The investigators used a semi-quantitative food-frequency questionnaire to ascertain consumption of regular and light beer, red and white wine, and liquor every 4 years. Alcohol consumption was categorized as light (0.1–9.9 g/d, or ⬍1 drink daily), moderate (10.0 –29.9 g/d, or 1 to 2 drinks daily), and heavier (ⱖ30.0 g/d, or ⱖ3 drinks daily). Results: During a follow-up period of 14 years, 412 cases of incident ischemic stroke were documented. Compared with abstainers, light drinkers had a multivariate-adjusted relative risk of 0.99 (95% CI, 0.72–1.37), moderate drinkers had a multivariate-adjusted relative risk of 1.26 (CI, 0.90 –1.76) and heavier drinkers had a multivariate-adjusted relative risk of 1.42 (CI, 0.97–2.09; p⫽0.01 for trend). Consumption of 10.0 to 29.9 g of alcohol per day 3 to 4 days per week appeared to be associated with the lowest risk (relative risk, 0.68 [CI, 0.44 –1.05]). Red wine consumption was inversely associated with risk in a graded manner (p⫽0.02 for trend), but other beverages were not. The apparently higher risk for ischemic stroke with heavier alcohol use appeared to be most pronounced for the embolic subtype. Conclusions: The researchers concluded that in this sample of male health professionals, light and moderate average alcohol use was generally not associated with an increased risk for ischemic stroke. Intake of more than 2 drinks per day may be associated with a higher risk for ischemic stroke. Perspective: The study suggests that alcohol consumption appears to be associated with a higher risk for ischemic stroke among men who consumed ⬎2 drinks per day, but this association was not apparent at lower levels of intake. A trend toward lower risk for stroke associated with light drinking was most evident for thrombotic stroke and for consumption of 1 to 2 drinks 3 to 4 days per week. Red wine consumption had an inverse association with ischemic stroke, but other alcoholic beverages did not. These findings support current public health recommendations stating that men should consume fewer than 2 drinks per day to help prevent ischemic stroke. The findings also support the
Study Question: Is there a protective effect of fish intake on the risk of strokes? Methods: The association of different types of fish meals with risk of stroke was measured in the Cardiovascular Health Study, a population-based longitudinal cohort study of determinants of cardiovascular events in the elderly. A total of 4775 adults, 65 years or older and free of cerebrovascular disease at baseline during 1989 –1990, underwent an assessment of usual dietary intake using a food-frequency questionnaire. Incident strokes and stroke subtype were prospectively ascertained. Results: Mean age was 72.7 years (range 65–98 years), 44% were male, 22% were diabetic, 45% had hypertension, mean LDL-C was 126 mg/dL, HDL-C 54 mg/dL, and mean internal carotid IMT was 1.6 mm. Fried/fish sandwich and tuna/other fish consumption averaged 0.7 and 2.2 servings per week, respectively. During 12 years of follow-up, 626 incident strokes occurred, including 529 ischemic strokes. In multivariate analyses, tuna/other fish consumption was inversely associated with total stroke (p⫽0.04) and ischemic stroke (p⫽0.02), with 27% lower risk of ischemic stroke with an intake of 1 to 4 times per week (HR, 0.73; 95%CI, 0.55– 0.98) and 30% lower risk with intake of 5 or more times per week (HR, 0.70; 95%CI, 0.50 – 0.99) compared with an intake of less than once per month. In contrast, fried fish/fish sandwich consumption was positively associated with total stroke (p⫽0.006) and ischemic stroke (p⫽0.003), with a 44% higher risk of ischemic stroke with consumption of more than once per week (HR, 1.44; 95%CI, 1.12–1.85) compared with consumption of less than once per month. Fish consumption was not associated with hemorrhagic stroke. Conclusions: Among elderly individuals, consumption of tuna or other broiled or baked fish is associated with lower risk of ischemic stroke, whereas intake of fried fish or fish sandwiches is associated with higher risk. These results suggest that fish consumption may influence stroke risk late in life; potential mechanisms and alternate explanations warrant further study. Perspective: There was no advantage of fish consumption ⬎4 times per week compared to 1 to 4 times. Previous population studies have yielded conflicting results. There are plausible biological mechanisms for beneficial effects of tuna/other fish intake on incidence of stroke, particularly ischemic stroke. In a subset of these patients, consumption of tuna or other broiled or baked fish (r⫽0.35), but not fried fish or fish sandwiches, correlated with plasma phos-
ACC CURRENT JOURNAL REVIEW April 2005
21
pholipid long-chain n-3 fatty acid levels. In experimental studies, n-3 fatty acids from fatty fish influence blood pressure, lipid levels, inflammatory responses, red blood cell deformability, endothelial cell function, and cerebral arteriolar reactivity. This study excluded persons using marine oil supplements, which have been shown to be beneficial postmyocardial infarction. MR
ministered when deferred diagnostic tests confirmed venous thromboembolism. Primary outcome included bleeding risk in persons without confirmed VTE, morbidity and mortality in missed VTE, and accuracy of the clinical protocol. Results: A total of 409 consecutive patients with suspected DVT and 124 with suspected PE were included in the study; 23.8% (95%CI, 20.3–27.3%) of patients had confirmed VTE. At the short-term follow-up (72 h), only a single thromboembolic event (0.2%; upper 95%CI, 0.6%) had occurred, whereas at the 3-month follow-up, 5 events (1.2%; 95%CI, 0.2–2.1%) had occurred in patients in whom diagnosis of DVT or PE had previously been ruled out. None of the patients had major bleeding events; 90% of participants were treated as outpatients. Conclusions: In patients with a suspected venous thromboembolism on presentation to an emergency room, treatment with heparin of only those patients with intermediate and high clinical probability who are D-dimer-positive allow for a safe deferral of diagnostic procedures for DVT and PE for up to 72 h. Perspective: The study was carried out in Italy where malpractice liability is considerably different from the U.S. Nevertheless, in the cohort with likely VTE, delaying testing for a few days does not increase the morbidity and mortality significantly in hemodynamically stable patients. MR
Deferment of Objective Assessment of Deep Vein Thrombosis and Pulmonary Embolism Without Increased Risk of Thrombosis Siragusa S, Anastasio R, Porta C, et al. Arch Intern Med 2004;164:2477– 82. Study Question: Can the pretest clinical probability (PCP), positive D-dimer and short-term use of low-molecular weight heparin (LMWH) safely allow a 72-h delay in the definitive evaluation of patients suspected to have deep vein thrombosis (DVT) and pulmonary embolism (PE) (combined as VTE)? Methods: Patients identified with a high PCP or a moderate PCP with positive D-dimer test results received a protective full-dose treatment of LMWH; the remaining patients were discharged without anticoagulant administration. All patients were scheduled to undergo objective tests for DVT or PE within 72 h. Standard antithrombotic therapy was ad-
ACC CURRENT JOURNAL REVIEW April 2005
22