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September 11, 2003 Vol. 349 No. 11
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In a large cohort of patients with nonvalvular atrial fibrillation, oral anticoagulation with warfarin that resulted in an international normalized ratio (INR) of 2.0 or greater not only reduced the risk of ischemic stroke but also reduced its severity and associated mortality. Less intense anticoagulation (an INR of less than 2.0) and aspirin therapy were both less effective. The risk of serious hemorrhage was low until the INR exceeded 3.9.
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Myocardial ischemia due to coronary microvascular dysfunction is believed to occur in patients with hypertrophic cardiomyopathy and may cause clinical events such as sudden death. In this study, coronary microvascular dysfunction was identified with the use of positron-emission tomography before and after the infusion of dipyridamole, a coronary vasodilator. Microvascular dysfunction, defined as an abnormal response to dipyridamole, was associated with an unfavorable outcome, including death from cardiovascular causes.
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In this randomized study of 460 patients receiving effective treatment for human immunodeficiency virus type 1 (HIV-1) disease, nevirapine, efavirenz, or abacavir was substituted for the protease inhibitor in a regimen that also included two nucleoside reverse-transcriptase inhibitors. After 12 months, the increases in CD4 cell counts were similar in the three groups, but there was a trend toward a higher rate of treatment failure in the abacavir group.
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Projections of future Medicare expenditures need to take into account the effects of life expectancy and health status on health care costs. In this study of Medicare patients, as expected, better health was associated with lower annual costs and longer lives. For persons in better health, the annual savings were offset by spending over more years, so that expenditures from 70 years of age until death were similar among persons in all initial health states.
A 72-year-old, college-educated woman comes in for the evaluation of mild memory loss that has been gradually progressing for the past two years. The patient drives her own car and manages her own finances, although she has recently made some errors in her checkbook. She also forgot the location of her car in a mall parking lot for two hours. How should this patient be evaluated and treated?
This article summarizes the available information regarding the cardiac risks of participation in athletics. Hypertrophic cardiomyopathy remains the leading cause of sudden death from cardiac causes among young athletes. Although controlled studies are lacking, there is indirect evidence to suggest that screening and sidelining young athletes with high-risk cardiac findings are justified and should decrease the number of sudden deaths in this population.
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