Dear Melissa, I have enjoyed very much your impressions for what is really new in AHA meeting.. We poor Greeks -esp.. me- cannot parrticipate in these meetings for obvious reasons..

Please, dont try even to think to come to Europe, esp. in ..Athens!. It is a real hell and "war situstion" -not only in the streets!..

I wonder: what about INITIAL SCREENING for the silent killers (subclinic CAD and cardiomyopathies) ??? Don't tell me about sophisticated -EXPENSIVE- imaging techniques and debatable echo stress tests..These are and will never become "true-cost effective" tools out-of-hospitals, something like Presso Test, I mean...

Melissa,

Regarding dronedarone, do you mean "permanent" instead of "persistent"?

Dave,

Sorry just now getting back into the hospital and office today. Didn't have time to reply until now! and yes, I believe permanent is best terminology!!!

Melissa

Bruce and Debra, thanks for reading!!! Glad you enjoyed the coverage!

Jan, I am so sorry for what has happened in your country. I hope things get better soon. I don't really have a feel for how your economics are affecting the day to day work in the cardiology office setting.

. With regard to out patient testing, I don't know what I'd do without an echo. Are you saying that all of your testing must be performed in the hospital setting?

Thanks for posting all.

Melissa

   I enjoyed your comments too!

On September 22-23 The European Medicines agency released their updated information on dronedarone (Multaq).further limiting the use of the drug.  Perhaps it would be good to prescribe for hemorroidal pain and acne...

    http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_- _Summary_for_the_public/human/001043/WC500044536.pdf

Sadly, I strongly concur with your irreverence. Like Bruce, going, in person, to these meetings neither fits into the schedule or the budget. Thank you for your summary. It seems largely in line with my impressions from other coverage.

Personally, I adopted enoxaparin first, then abciximab and later bivalirudin, as my preferred interventional clot reducers generally within a few months of their becoming available. In retrospect/hindsight, as most of our judgements are made, those calls seem to have worked out fairly well, as options for treating the complications for end-stage disease disasters go.

I had considerable experience with amiodarone, as a fellow in a program which was part of the FDA pre-approval process for amiodarone. From this experience, I knew to be extremely wary of this agent, even more-so all the Class 1 "anti-arrhythmic" compounds, which all further complicate the already extra-complex continued-life-threatening complexity within people who are prescribed these compounds. I was not at all surprised by the results of the Cardiac Arrhythmia Suppression Trial. From clinical experience, I had expected results similar to what were found.

While I had hopes for dronedarone, I had given samples and prescribed this compound, if memory serves me correctly, to only one person and only on a short term trial basis, the rest had stayed on my samples shelves.

The "AIM-HIGH" trial, and especially the conclusions promoted, seem like another example of a badly designed trial focusing more on costs, the wrong biomarkers and promotion of academic publication (publish-or-perish) than client success.

I made a critique of my difficulties with "AIM-HIGH" in comment 11 on web-page: http://www.theheart.org/article/1312479.do?utm_campaign=newsletter&utm_medium=email&utm_source=20111115_AHA_EN_01_R01.

Similar to C McConnell, comment 11 on the above page, I adopted utilizing high-dose (typically ~2K/day, but very client dependant) time-release niacin, specifically the Enduracin brand, in 1995 after seeing a male client one day who was taking 2K/day, and both (a) had unusually good lipid numbers, for a male his age and situation, and (b) denied the usual problems. I honed in on what he was doing and how he found out about this product. Of course, like all the other preparations on the market, a good bit of client education and written instructions are crucial to client success. while Enduracin also has its problems, mostly availability and marketing. It was not until it finally dawned on me, in ~2003, to simply stock it in the office that things start working out much better with the vast majority of clients who will only do what-is-easier and will only purchase locally.

When the Niaspan option became available, I tried it personally, but also quickly found that once one achieves daily doses sufficient to be effective (even divided 2-3 times/day), the product was both very unpredictable and commonly induced intense head to toe intense flushing, onset many hours after ingestion. Yes, Niaspan is time-release, but unpredictable and variable time-release with the flushing response sometimes, if not frequently, hitting like a bombshell. One does not understand until taking it, it is hard to explain to someone else and others do not believe until experiencing the results personally. In all the years since Niaspan has been available, I have only had a couple of clients who stuck with it, after comparing with the much less expensive Enduracin alternative, and even then they said the only reason was because their co-pay for Niaspan was zero (and they were used to the problems).

After discovering the availability of the relatively inexpensive NMR lipoprotein assay in ~1998, along with additional improving LDL (not LDL-C) dietary and supplement tools (plus no longer taking hospital ER call circa ~2005), I rarely have a client who gets into so much trouble that they have need for interventional procedures, performed by myself or anyone else. The frequency is down to less than one/year. Of course, in the disease payment system we have in the US, this situation is very bad for income. However, it is good for clients.

Like in most of life, survival seems to depend on being the fittest: more successful genes, self-discipline, food control, monetary success, sales success and "research study" marketing success.

As we all know, the best, perhaps most-needed studies never get done. The studies that do get performed are largely driven by academic interests and sales dollars. As client advisors, we are largely left to do a lot of guessing, highly influenced by our own experience and biases along with those of the clients we see.

And so it goes.

Fascinated by the thread, and agree that the interpretation of the conference matches neatly (and much more entertainingly) with other sources. Melissa, your comments re colcichine brought to mind a lecturer many years ago dismissing colcichine as ' a useful drug frantically looking for a disease'... 

As a question (Milton and Melssa), what would be a 'wish list' for the five studies that most need to be done?

Absolultely LOVED your comment regarding medication alone not being the answer for CHF patients. I am an advanced practice nurse with a group of nurse-researchers at UK College of Nursing, led by Drs. Debra Moser, Terry Lennie, Misook Chung, and Susan Frazier. For some years now, many of our interventional studies with HF patients, and caregivers, have included education about sodium and fluid as a part of symptom management. Through these research projects, we have been on the front-line of attempting to help HF patients change their behaviors. I have shared your editorial with several members of our research team who join me in supporting your opinion about HF management.