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Physician inertia in dealing with hypercholesterolemia discovered during hospitalizatlon
RgADERS
COMMENTS
Physician Inertia In Dealing with Hypercholesterolemia Discovered During Hospitalization Kudos to William Roberts, Editor inChief of The American Journal of Cardiolonv, for this article entitled “LinidLowering Therapy After an Atheros’clerotic Event.“’ With a claritv that belies the careful consideration given to a difficult and controversial subject, Dr. Roberts has made the case for lipid-lowering therapy after an atherosclerotic event. He clearly states that we must treat serum cholesterol levels in persons after an acute atherosclerotic event differently from the so-called standard population at risk. While there will be opponents to his viewpoint, particularly since many physicians have become resentful of the media hype related to the National Cholesterol Education Program, the validity of this approach has been established by the many references cited. In this controversial and confrontational area of therapy, little has been said about the physician inertia that nreceded the current therapeutic enthusiasm for both drums and diet. In 1986. I renorted on “Hypercholesterolemia During kospitalization.“* In that article, I identified 38 patients admitted to a medical school teaching hospital in upstate New York in whom a cholesterol level >350 mg/dl was noted during hospital admission. Patients with clearly identified secondary hyperlipidemia such as due to thyroid disease, nephrotic syndrome, lymphoma, biliary cirrhosis and diabetic ketoacidosis were excluded. The cholesterol in this group of patients varied from 35 1 to 1,060 mg/dl; yet during the hospitalization only 14 of them had cholesterol measurements repeated, and only in 13 was the diagnosis of hyperlipidemia made. The physician wrote a dietary order related to hyperlipidemia in only 9 cases. Twenty-three of these patients had documented vascular disease during their present hospital stay including coronary artery disease, peripheral vascular disease and cerebral vascular disease. One patient, a 40-year-old male smoker with a history of coronary artery disease and hypertension, had a cholesterol level of 414 mg/dl, and received neither dietary nor drug therapy. The diagnosis of hyperlipidemia had not been noted on this patient’s chart and no lipid determinations were made during follow-up. While the cost of lipid-lowering dietary and drug therapy is real, and there is room for further research into the effect of such therapy in women and the elderly, the necessity for treatment has been clearly outlined.
1410
THE AMERICAN
JOURNAL
For those therapeutic nihilists who take objection to the current media blitz on cholesterol, perhaps a closer analysis of the situation in American teaching hospitals before the National Cholesterol Education Program merits attention. David T. Nash, MD Syracuse, New York 2 October
1989
1. Roberts WC. Lipid-lowering therapy an atherosclerotic event. Am J Curdiol
after 1989;
64.693-695. 2. Nash DT. Hypercholesterolemia
pitalization. The case for closer Postgrad Med 1986;79:303-310.
during hossurveillance.
Maternal and Fetal Sequelae of Anticoagulation During Pregnancy In the study by Sareli et al,’ the finding of a high incidence of fetal wastage was not surprising, since warfarin is a known teratogen.rm4 Heparin has been shown to be relatively safe and effective during pregnancy in the setting of prosthetic valves.5s6 Because of warfarin’s known teratogenicity, and the existence of a safe alternative therapy, it seems logical that heparin should be used instead of warfarin in this clinical setting. The study by Sareli et al raises certain issues of concern. Physicians would be placing themselves at great risk of liability for prescribing warfarin to a pregnant woman or a woman thinking of having children. Any woman of childbearing age should be advised to stop taking warfarin before becoming pregnant. Subcutaneous heparin can be safely substituted before conception, whether for prosthetic valves or deep vein thrombosis-prophylaxis.6 We believe the issue of warfarin teratogenicity is well enough established to obviate the need for future studies placing unborn children at risk for fetal malformations, hemorrhage or death.
OF CARDIOLOGY
Jeffrey
Keith C. Myers, M. Nakamura,
YID MD
Honolulu, Hawaii 23 August 1989
TABLE
I Main
Findings
of the
1. Sareli P, England MJ, Berk MR, Marcus RH, Epstein M, Driscoll J, Meyer T, McIntyre J, van Gelderen C. Maternal and fetal sequelae of anticoagulation during pregnancy in patients with mechanical heart valve prosthesis. Am J Cardiot 1989,63:1462-1465. 2. Avery GS, ed. Drug Treatment: Principles and Practice of Clinical Pharmacology and Therpeutics, second edition. New York: ADIS Press, 1980:467. 3. Sham WL, Hall JG. Multiple congenital abnormalities associated with oral anticoagulants. Am J Ob Gyn 1977:127:191. 4. Physicians’ Desk Reference, 1989. 5. Lee PK, Wann RYC. Chow JSF. et al. Combined use of wa;farin and adjusted subcutaneous heparin during pregnancy in patients with artificial heart valves. JACC 1986X3:221 -224. 6. Salazar E, Zajarias A, Gutierrez N, Iturbe I. The problem of cardiac valve prosthesis, anticoagulants, and pregnancy. C&ulation 1984; 7O(suppl1):1-169-I-177.
We fully agree with these comments regarding the substitution of warfarin by heparin before conception to avoid warfarin embryopathy in live-born infants in patients with prosthetic valves. Unfortunately, as we stated in our article no “patients had reported for preconceptual counseling,” probably based on some cultural tradition. They continued to take warfarin throughout the first trimester. However the documented rate of embryopathy in live-born infants in our study group was only 41, which is relatively low. We stated at the end of our article that “controlled studies of heparin anticoagulation started before conception and continued throughout pregnancy may improve fetal prognosis in this group of patients.” REPLY:
Pinhar
VOLUME
65
MD
In the July 18, 1989, AJC symposium issue, Table I on page 30B is incorrect. The columns under- the Coumarin Therapy and Placebo Group headings should be switched. The corrected Table appears here:
Dutch
Sixty
Plus Reinfarction
Study3
Reinfarction Receiving treatment Intention to treat Deaths Receiving treatment Intention to treat
Sareli,
Johannesburg, South Africa 26 September 1989
Coumarin Therapy (n = 439)
Placebo Group (n = 439)
p Value
20 29
58 64
0.0001 o.ooo5
28 51
49 69
0.017 0.071
COMMENTS
Physician Inertia In Dealing with Hypercholesterolemia Discovered During Hospitalization Kudos to William Roberts, Editor inChief of The American Journal of Cardiolonv, for this article entitled “LinidLowering Therapy After an Atheros’clerotic Event.“’ With a claritv that belies the careful consideration given to a difficult and controversial subject, Dr. Roberts has made the case for lipid-lowering therapy after an atherosclerotic event. He clearly states that we must treat serum cholesterol levels in persons after an acute atherosclerotic event differently from the so-called standard population at risk. While there will be opponents to his viewpoint, particularly since many physicians have become resentful of the media hype related to the National Cholesterol Education Program, the validity of this approach has been established by the many references cited. In this controversial and confrontational area of therapy, little has been said about the physician inertia that nreceded the current therapeutic enthusiasm for both drums and diet. In 1986. I renorted on “Hypercholesterolemia During kospitalization.“* In that article, I identified 38 patients admitted to a medical school teaching hospital in upstate New York in whom a cholesterol level >350 mg/dl was noted during hospital admission. Patients with clearly identified secondary hyperlipidemia such as due to thyroid disease, nephrotic syndrome, lymphoma, biliary cirrhosis and diabetic ketoacidosis were excluded. The cholesterol in this group of patients varied from 35 1 to 1,060 mg/dl; yet during the hospitalization only 14 of them had cholesterol measurements repeated, and only in 13 was the diagnosis of hyperlipidemia made. The physician wrote a dietary order related to hyperlipidemia in only 9 cases. Twenty-three of these patients had documented vascular disease during their present hospital stay including coronary artery disease, peripheral vascular disease and cerebral vascular disease. One patient, a 40-year-old male smoker with a history of coronary artery disease and hypertension, had a cholesterol level of 414 mg/dl, and received neither dietary nor drug therapy. The diagnosis of hyperlipidemia had not been noted on this patient’s chart and no lipid determinations were made during follow-up. While the cost of lipid-lowering dietary and drug therapy is real, and there is room for further research into the effect of such therapy in women and the elderly, the necessity for treatment has been clearly outlined.
1410
THE AMERICAN
JOURNAL
For those therapeutic nihilists who take objection to the current media blitz on cholesterol, perhaps a closer analysis of the situation in American teaching hospitals before the National Cholesterol Education Program merits attention. David T. Nash, MD Syracuse, New York 2 October
1989
1. Roberts WC. Lipid-lowering therapy an atherosclerotic event. Am J Curdiol
after 1989;
64.693-695. 2. Nash DT. Hypercholesterolemia
pitalization. The case for closer Postgrad Med 1986;79:303-310.
during hossurveillance.
Maternal and Fetal Sequelae of Anticoagulation During Pregnancy In the study by Sareli et al,’ the finding of a high incidence of fetal wastage was not surprising, since warfarin is a known teratogen.rm4 Heparin has been shown to be relatively safe and effective during pregnancy in the setting of prosthetic valves.5s6 Because of warfarin’s known teratogenicity, and the existence of a safe alternative therapy, it seems logical that heparin should be used instead of warfarin in this clinical setting. The study by Sareli et al raises certain issues of concern. Physicians would be placing themselves at great risk of liability for prescribing warfarin to a pregnant woman or a woman thinking of having children. Any woman of childbearing age should be advised to stop taking warfarin before becoming pregnant. Subcutaneous heparin can be safely substituted before conception, whether for prosthetic valves or deep vein thrombosis-prophylaxis.6 We believe the issue of warfarin teratogenicity is well enough established to obviate the need for future studies placing unborn children at risk for fetal malformations, hemorrhage or death.
OF CARDIOLOGY
Jeffrey
Keith C. Myers, M. Nakamura,
YID MD
Honolulu, Hawaii 23 August 1989
TABLE
I Main
Findings
of the
1. Sareli P, England MJ, Berk MR, Marcus RH, Epstein M, Driscoll J, Meyer T, McIntyre J, van Gelderen C. Maternal and fetal sequelae of anticoagulation during pregnancy in patients with mechanical heart valve prosthesis. Am J Cardiot 1989,63:1462-1465. 2. Avery GS, ed. Drug Treatment: Principles and Practice of Clinical Pharmacology and Therpeutics, second edition. New York: ADIS Press, 1980:467. 3. Sham WL, Hall JG. Multiple congenital abnormalities associated with oral anticoagulants. Am J Ob Gyn 1977:127:191. 4. Physicians’ Desk Reference, 1989. 5. Lee PK, Wann RYC. Chow JSF. et al. Combined use of wa;farin and adjusted subcutaneous heparin during pregnancy in patients with artificial heart valves. JACC 1986X3:221 -224. 6. Salazar E, Zajarias A, Gutierrez N, Iturbe I. The problem of cardiac valve prosthesis, anticoagulants, and pregnancy. C&ulation 1984; 7O(suppl1):1-169-I-177.
We fully agree with these comments regarding the substitution of warfarin by heparin before conception to avoid warfarin embryopathy in live-born infants in patients with prosthetic valves. Unfortunately, as we stated in our article no “patients had reported for preconceptual counseling,” probably based on some cultural tradition. They continued to take warfarin throughout the first trimester. However the documented rate of embryopathy in live-born infants in our study group was only 41, which is relatively low. We stated at the end of our article that “controlled studies of heparin anticoagulation started before conception and continued throughout pregnancy may improve fetal prognosis in this group of patients.” REPLY:
Pinhar
VOLUME
65
MD
In the July 18, 1989, AJC symposium issue, Table I on page 30B is incorrect. The columns under- the Coumarin Therapy and Placebo Group headings should be switched. The corrected Table appears here:
Dutch
Sixty
Plus Reinfarction
Study3
Reinfarction Receiving treatment Intention to treat Deaths Receiving treatment Intention to treat
Sareli,
Johannesburg, South Africa 26 September 1989
Coumarin Therapy (n = 439)
Placebo Group (n = 439)
p Value
20 29
58 64
0.0001 o.ooo5
28 51
49 69
0.017 0.071