Letters
However, the onset of the HIV epidemic brought about a shift. As Drago and colleagues note, successful outcomes depend on the integrity of the immune response of the host, a crucial issue given multiple reports of neurological relapses occurring after recommended penicillin treatment in individuals with HIV. These reports, however, surfaced before the advent of effective antiretroviral therapy. Patients with HIV have been shown to have lower rates of neurosyphilis when their HIV infection is treated,6 and the availability of effective antiretroviral therapy has helped alleviate concerns regarding HIV-induced immunosuppression. Given the advantages of single-dose therapy for earlystage syphilis and the relatively low rate of posttreatment clinical neurosyphilis in the contemporary era, we believe that improved outcomes overall will result from investment in better surveillance systems for early-stage syphilis, increased adherence to therapy, close follow-up of all infected patients, and expanded access to effective antiretroviral therapy for those with HIV infection. Meredith E. Clement, MD N. Lance Okeke, MD Charles B. Hicks, MD Author Affiliations: Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina (Clement, Okeke); Division of Infectious Diseases, University of California, San Diego (Hicks). Corresponding Author: Charles B. Hicks, MD, Divisions of General Internal Medicine/Infectious Diseases, University of California, San Diego, 200 W Arbor Dr, San Diego, CA 92103 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
In a preliminary study, Liangos et al2 found rapid increases in the levels of several chemokines and adhesion molecules after cardiopulmonary bypass in patients developing AKI, suggesting a strong interaction between hemodynamic and inflammatory mechanisms. The therapeutic intervention was performed a median of 32 hours (interquartile range, 26-52 hours) after initiation of the surgery. This late initiation of treatment might have contributed to the negative findings of the study. Although inclusion of patients at development of AKI might be perceived as early recognition and the performed intervention as timely, the authors’ definition of AKI required an increase in serum creatinine level of at least 50%. The trends in serum creatinine level reported in Figure 2 in the article suggest that patients experienced their initial renal insult during rather than after surgery. Furthermore, at intensive care unit admission an increase in serum creatinine level was already observed despite expected positive fluid balance during surgery, showing that a substantial drop in glomerular filtration rate (GFR) had already occurrred.3 The early increase in renal tubule injury biomarkers compared with the later elevation in serum creatinine level after cardiopulmonary bypass has been found in several studies. 4 By the second postoperative day, when fenoldopam was initiated, patients already had wellestablished AKI, and dopamine agonists would be expected to lack effectiveness in reversing renal hypoperfusion and may even have worsened renal perfusion.5 Although the study adds important information, the success of a therapeutic intervention may depend on early inclusion of patients after renal insult. In future interventional trials, treatment should be based on biomarkers allowing early detection of kidney injury and not on late detection of loss of function.
1. Morrison RE, Harrison SM, Tramont EC. Oral amoxycillin, an alternative treatment for neurosyphilis. Genitourin Med. 1985;61(6):359-362. 2. Rolfs RT, Joesoef MR, Hendershot EF, et al; Syphilis and HIV Study Group. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med. 1997;337(5): 307-314. 3. Ghanem KG. Neurosyphilis: a historical perspective and review. CNS Neurosci Ther. 2010;16(5):e157-e168. 4. Perdrup A, Jørgensen BB, Pedersen NS. The profile of neurosyphilis in Denmark: a clinical and serological study of all patients in Denmark with neurosyphilis disclosed in the years 1971-1979 incl by Wassermann reaction (CWRM) in the cerebrospinal fluid. Acta Derm Venereol Suppl (Stockh). 1981;96: 1-14. 5. Jaffe HW, Kabins SA. Examination of cerebrospinal fluid in patients with syphilis. Rev Infect Dis. 1982;4:S842-S847. 6. Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS. 2008;22(10): 1145-1151.
Fenoldopam and Acute Kidney Injury To the Editor The trial by Dr Bove and colleagues1 found that the renal vasodilator fenoldopam did not reverse acute kidney injury (AKI) after cardiac surgery, in contrast to previous trials and meta-analyses. The failure of this selective renal vasodilator to prevent further deterioration of AKI supports current concepts that several pathophysiological mechanisms besides renal hypoperfusion are involved in AKI associated with on-pump cardiac surgery. 970
Matthieu Legrand, MD, PhD Michael Darmon, MD, PhD Michael Joannidis, MD, PhD Author Affiliations: Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, St Louis Lariboisière, Paris, France (Legrand); Medical-Surgical ICU, Hôpital Nord, St Priest en Jarez, Saint-Etienne, France (Darmon); Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria (Joannidis). Corresponding Author: Matthieu Legrand, MD, PhD, Department of Anesthesiology and Critical Care and Burn Unit, St Louis Hospital, Université Paris Diderot–Paris 7, 1 Rue Claude Vellefaux, 75010 Paris, France (matthieu.m [email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Legrand reported receiving lecture fees from Alere and Gilead and consulting fees from Astellas. Dr Darmon reported receiving logistical research support from Astutos Medical; receiving a grant and logistical research support from Saint-Etienne University Hospital; and being a moderator at a symposium for Hospal. Dr Joannidis reported receiving speaking fees from Baxter, Gambro, Fresenius, CLS Behring, Braun, and Astute and consulting fees from AM Pharma. 1. Bove T, Zangrillo A, Guarracino F, et al. Effect of fenoldopam on use of renal replacement therapy among patients with acute kidney injury after cardiac surgery: a randomized clinical trial. JAMA. 2014;312(21):2244-2253. 2. Liangos O, Addabbo F, Tighiouart H, Goligorsky M, Jaber BL. Exploration of disease mechanism in acute kidney injury using a multiplex bead array assay: a nested case-control pilot study. Biomarkers. 2010;15(5):436-445. 3. Waikar SS, Bonventre JV. Creatinine kinetics and the definition of acute kidney injury. J Am Soc Nephrol. 2009;20(3):672-679.
JAMA March 3, 2015 Volume 313, Number 9 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
jama.com
Letters
4. Meersch M, Schmidt C, Van Aken H, et al. Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. PLoS One. 2014;9(3):e93460. 5. Lauschke A, Teichgräber UKM, Frei U, Eckardt K-U. “Low-dose” dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int. 2006;69 (9):1669-1674.
In Reply We agree with Dr Legrand and colleagues that our study provides further indirect evidence that nonhemodynamic factors may be important to the pathogenesis of AKI after cardiac surgery. We also agree that increases in serum creatinine level represent an already advanced level of decreased GFR, at which time interventions may be less likely to succeed in preserving GFR. However, in a previous randomized double-blind clinical trial of fenoldopam in which the drug was given at anesthesia induction, we also failed to see a beneficial effect.1 Moreover, although we have conducted several studies of renal biomarkers in the setting of cardiac surgery and the development of AKI,2-4 we are not aware of any studies conducted among cardiac surgery patients in which interventions triggered by novel biomarkers instead of creatinine level delivered better functional outcomes. Thus, the putative advantage of biomarkertriggered interventions, although interesting and perhaps logical, remains theoretical at this stage. Tiziana Bove, MD Giovanni Landoni, MD Rinaldo Bellomo, MD Author Affiliations: IRCCS San Raffaele Scientific Institute, Milan, Italy (Bove, Landoni); Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia (Bellomo). Corresponding Author: Giovanni Landoni, MD, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The IRCCS San Raffaele Scientific Institute received a grant from the Italian Ministry of Health to conduct the study and received an unrelated donation from Teva. No other disclosures were reported. 1. Bove T, Landoni G, Calabrò MG, et al. Renoprotective action of fenoldopam in high-risk patients undergoing cardiac surgery: a prospective, double-blind, randomized clinical trial. Circulation. 2005;111(24):3230-3235. 2. Silvetti S, Meroni R, Bignami E, et al. Preoperative urinary neutrophil gelatinase-associated lipocalin and outcome in high-risk heart failure patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2014;28(2):323-327. 3. Haase M, Bellomo R, Albert C, et al. The identification of three novel biomarkers of major adverse kidney events. Biomark Med. 2014;8(10):1207-1217. 4. Glassford NJ, Schneider AG, Xu S, et al. The nature and discriminatory value of urinary neutrophil gelatinase-associated lipocalin in critically ill patients at risk of acute kidney injury. Intensive Care Med. 2013;39(10):1714-1724.
Multifactorial Risk Assessment for Atherosclerotic Cardiovascular Disease To the Editor Drs Stine and Chokshi1 suggested that with the arrival of the new American College of Cardiology/American Heart Association guidelines for lipid reduction to reduce adverse outcomes from atherosclerotic cardiovascular disease, it is time to move from a low-density lipoprotein cholesterol target basis to a “multifactorial risk assessment,” especially since online calculators now make it easy to perform quantitation and may even jama.com
provide patient education tools (using simple natural frequency displays) to facilitate shared decision making. As sensible as this recommendation seems, it may be too soon to implement it for at least 3 reasons. First, existing tools appear to overstate the likelihood of coronary events2 or, equally troubling, are inconsistent while purporting to address the same risk groups.3 Second, results from online calculators lack error estimates (such as confidence intervals) to permit physicians to address uncertainty in discussions with their patients. Third, statistical numeracy among practicing physicians is far from satisfactory, undermining the practical value of those time-consuming discussions. There are instructive lessons regarding tools assessing multiple risk factors in other screening venues. For example, the World Health Organization’s Fracture Risk Assessment Tool (FRAX) has been available since 2008 and is strongly supported by professional organizations advocating its use in identifying individuals for prophylactic therapy to prevent osteoporosis-associated fractures.4 The FRAX online calculator5 stratifies risk by sex, race, geographic locale, and multiple influences on bone metabolism. Yet since the appearance of the online calculator in 2011, only about 3 million hits have been registered on the US-specific page.5 Because the lifetime risk for an osteoporotic fracture of the wrist, hip, or vertebrae approaches 40% in women in developed countries, and since medication can reduce this risk by about one-third, the calculator would appear to be vastly underused. There are approximately 41 million women older than 50 years in the United States whose risk for osteoporosis can be rapidly assessed using FRAX, which may then be supplemented with a dual-energy x-ray absorptiometry scan. Statistical illiteracy among physicians may in part be to blame for underuse of quantitative calculators, even for those like FRAX that almost certainly could help direct costeffective primary preventive therapies. It would seem prudent to forestall systemic application of new quantitative risk calculation for preventive intervention–related decision making in cardiovascular disease until there is supportive evidence of benefit to patients in controlled trials. Until then, straightforward cholesterol target guidelines may be best. Alan P. Zelicoff, MD Author Affiliation: Department of Environmental and Occupational Health, College for Public Health and Social Justice, St Louis University, St Louis, Missouri. Corresponding Author: Alan P. Zelicoff, MD, Department of Environmental and Occupational Health, College for Public Health and Social Justice, St Louis University, 3545 Lafayette Ave, St Louis, MO 63118 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Stine NW, Chokshi DA. Elimination of lipid levels from quality measures: implications and alternatives. JAMA. 2014;312(19):1971-1972. 2. Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women’s Health Study. JAMA Intern Med. 2014;174(12):1964-1971. 3. Allan GM, Nouri F, Korownyk C, Kolber MR, Vandermeer B, McCormack J. Agreement among cardiovascular disease risk calculators. Circulation. 2013;127 (19):1948-1956.
(Reprinted) JAMA March 3, 2015 Volume 313, Number 9
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
971
However, the onset of the HIV epidemic brought about a shift. As Drago and colleagues note, successful outcomes depend on the integrity of the immune response of the host, a crucial issue given multiple reports of neurological relapses occurring after recommended penicillin treatment in individuals with HIV. These reports, however, surfaced before the advent of effective antiretroviral therapy. Patients with HIV have been shown to have lower rates of neurosyphilis when their HIV infection is treated,6 and the availability of effective antiretroviral therapy has helped alleviate concerns regarding HIV-induced immunosuppression. Given the advantages of single-dose therapy for earlystage syphilis and the relatively low rate of posttreatment clinical neurosyphilis in the contemporary era, we believe that improved outcomes overall will result from investment in better surveillance systems for early-stage syphilis, increased adherence to therapy, close follow-up of all infected patients, and expanded access to effective antiretroviral therapy for those with HIV infection. Meredith E. Clement, MD N. Lance Okeke, MD Charles B. Hicks, MD Author Affiliations: Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina (Clement, Okeke); Division of Infectious Diseases, University of California, San Diego (Hicks). Corresponding Author: Charles B. Hicks, MD, Divisions of General Internal Medicine/Infectious Diseases, University of California, San Diego, 200 W Arbor Dr, San Diego, CA 92103 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
In a preliminary study, Liangos et al2 found rapid increases in the levels of several chemokines and adhesion molecules after cardiopulmonary bypass in patients developing AKI, suggesting a strong interaction between hemodynamic and inflammatory mechanisms. The therapeutic intervention was performed a median of 32 hours (interquartile range, 26-52 hours) after initiation of the surgery. This late initiation of treatment might have contributed to the negative findings of the study. Although inclusion of patients at development of AKI might be perceived as early recognition and the performed intervention as timely, the authors’ definition of AKI required an increase in serum creatinine level of at least 50%. The trends in serum creatinine level reported in Figure 2 in the article suggest that patients experienced their initial renal insult during rather than after surgery. Furthermore, at intensive care unit admission an increase in serum creatinine level was already observed despite expected positive fluid balance during surgery, showing that a substantial drop in glomerular filtration rate (GFR) had already occurrred.3 The early increase in renal tubule injury biomarkers compared with the later elevation in serum creatinine level after cardiopulmonary bypass has been found in several studies. 4 By the second postoperative day, when fenoldopam was initiated, patients already had wellestablished AKI, and dopamine agonists would be expected to lack effectiveness in reversing renal hypoperfusion and may even have worsened renal perfusion.5 Although the study adds important information, the success of a therapeutic intervention may depend on early inclusion of patients after renal insult. In future interventional trials, treatment should be based on biomarkers allowing early detection of kidney injury and not on late detection of loss of function.
1. Morrison RE, Harrison SM, Tramont EC. Oral amoxycillin, an alternative treatment for neurosyphilis. Genitourin Med. 1985;61(6):359-362. 2. Rolfs RT, Joesoef MR, Hendershot EF, et al; Syphilis and HIV Study Group. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. N Engl J Med. 1997;337(5): 307-314. 3. Ghanem KG. Neurosyphilis: a historical perspective and review. CNS Neurosci Ther. 2010;16(5):e157-e168. 4. Perdrup A, Jørgensen BB, Pedersen NS. The profile of neurosyphilis in Denmark: a clinical and serological study of all patients in Denmark with neurosyphilis disclosed in the years 1971-1979 incl by Wassermann reaction (CWRM) in the cerebrospinal fluid. Acta Derm Venereol Suppl (Stockh). 1981;96: 1-14. 5. Jaffe HW, Kabins SA. Examination of cerebrospinal fluid in patients with syphilis. Rev Infect Dis. 1982;4:S842-S847. 6. Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS. 2008;22(10): 1145-1151.
Fenoldopam and Acute Kidney Injury To the Editor The trial by Dr Bove and colleagues1 found that the renal vasodilator fenoldopam did not reverse acute kidney injury (AKI) after cardiac surgery, in contrast to previous trials and meta-analyses. The failure of this selective renal vasodilator to prevent further deterioration of AKI supports current concepts that several pathophysiological mechanisms besides renal hypoperfusion are involved in AKI associated with on-pump cardiac surgery. 970
Matthieu Legrand, MD, PhD Michael Darmon, MD, PhD Michael Joannidis, MD, PhD Author Affiliations: Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, St Louis Lariboisière, Paris, France (Legrand); Medical-Surgical ICU, Hôpital Nord, St Priest en Jarez, Saint-Etienne, France (Darmon); Division of Intensive Care and Emergency Medicine, Medical University of Innsbruck, Innsbruck, Austria (Joannidis). Corresponding Author: Matthieu Legrand, MD, PhD, Department of Anesthesiology and Critical Care and Burn Unit, St Louis Hospital, Université Paris Diderot–Paris 7, 1 Rue Claude Vellefaux, 75010 Paris, France (matthieu.m [email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Legrand reported receiving lecture fees from Alere and Gilead and consulting fees from Astellas. Dr Darmon reported receiving logistical research support from Astutos Medical; receiving a grant and logistical research support from Saint-Etienne University Hospital; and being a moderator at a symposium for Hospal. Dr Joannidis reported receiving speaking fees from Baxter, Gambro, Fresenius, CLS Behring, Braun, and Astute and consulting fees from AM Pharma. 1. Bove T, Zangrillo A, Guarracino F, et al. Effect of fenoldopam on use of renal replacement therapy among patients with acute kidney injury after cardiac surgery: a randomized clinical trial. JAMA. 2014;312(21):2244-2253. 2. Liangos O, Addabbo F, Tighiouart H, Goligorsky M, Jaber BL. Exploration of disease mechanism in acute kidney injury using a multiplex bead array assay: a nested case-control pilot study. Biomarkers. 2010;15(5):436-445. 3. Waikar SS, Bonventre JV. Creatinine kinetics and the definition of acute kidney injury. J Am Soc Nephrol. 2009;20(3):672-679.
JAMA March 3, 2015 Volume 313, Number 9 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
jama.com
Letters
4. Meersch M, Schmidt C, Van Aken H, et al. Urinary TIMP-2 and IGFBP7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. PLoS One. 2014;9(3):e93460. 5. Lauschke A, Teichgräber UKM, Frei U, Eckardt K-U. “Low-dose” dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int. 2006;69 (9):1669-1674.
In Reply We agree with Dr Legrand and colleagues that our study provides further indirect evidence that nonhemodynamic factors may be important to the pathogenesis of AKI after cardiac surgery. We also agree that increases in serum creatinine level represent an already advanced level of decreased GFR, at which time interventions may be less likely to succeed in preserving GFR. However, in a previous randomized double-blind clinical trial of fenoldopam in which the drug was given at anesthesia induction, we also failed to see a beneficial effect.1 Moreover, although we have conducted several studies of renal biomarkers in the setting of cardiac surgery and the development of AKI,2-4 we are not aware of any studies conducted among cardiac surgery patients in which interventions triggered by novel biomarkers instead of creatinine level delivered better functional outcomes. Thus, the putative advantage of biomarkertriggered interventions, although interesting and perhaps logical, remains theoretical at this stage. Tiziana Bove, MD Giovanni Landoni, MD Rinaldo Bellomo, MD Author Affiliations: IRCCS San Raffaele Scientific Institute, Milan, Italy (Bove, Landoni); Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Melbourne, Australia (Bellomo). Corresponding Author: Giovanni Landoni, MD, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The IRCCS San Raffaele Scientific Institute received a grant from the Italian Ministry of Health to conduct the study and received an unrelated donation from Teva. No other disclosures were reported. 1. Bove T, Landoni G, Calabrò MG, et al. Renoprotective action of fenoldopam in high-risk patients undergoing cardiac surgery: a prospective, double-blind, randomized clinical trial. Circulation. 2005;111(24):3230-3235. 2. Silvetti S, Meroni R, Bignami E, et al. Preoperative urinary neutrophil gelatinase-associated lipocalin and outcome in high-risk heart failure patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth. 2014;28(2):323-327. 3. Haase M, Bellomo R, Albert C, et al. The identification of three novel biomarkers of major adverse kidney events. Biomark Med. 2014;8(10):1207-1217. 4. Glassford NJ, Schneider AG, Xu S, et al. The nature and discriminatory value of urinary neutrophil gelatinase-associated lipocalin in critically ill patients at risk of acute kidney injury. Intensive Care Med. 2013;39(10):1714-1724.
Multifactorial Risk Assessment for Atherosclerotic Cardiovascular Disease To the Editor Drs Stine and Chokshi1 suggested that with the arrival of the new American College of Cardiology/American Heart Association guidelines for lipid reduction to reduce adverse outcomes from atherosclerotic cardiovascular disease, it is time to move from a low-density lipoprotein cholesterol target basis to a “multifactorial risk assessment,” especially since online calculators now make it easy to perform quantitation and may even jama.com
provide patient education tools (using simple natural frequency displays) to facilitate shared decision making. As sensible as this recommendation seems, it may be too soon to implement it for at least 3 reasons. First, existing tools appear to overstate the likelihood of coronary events2 or, equally troubling, are inconsistent while purporting to address the same risk groups.3 Second, results from online calculators lack error estimates (such as confidence intervals) to permit physicians to address uncertainty in discussions with their patients. Third, statistical numeracy among practicing physicians is far from satisfactory, undermining the practical value of those time-consuming discussions. There are instructive lessons regarding tools assessing multiple risk factors in other screening venues. For example, the World Health Organization’s Fracture Risk Assessment Tool (FRAX) has been available since 2008 and is strongly supported by professional organizations advocating its use in identifying individuals for prophylactic therapy to prevent osteoporosis-associated fractures.4 The FRAX online calculator5 stratifies risk by sex, race, geographic locale, and multiple influences on bone metabolism. Yet since the appearance of the online calculator in 2011, only about 3 million hits have been registered on the US-specific page.5 Because the lifetime risk for an osteoporotic fracture of the wrist, hip, or vertebrae approaches 40% in women in developed countries, and since medication can reduce this risk by about one-third, the calculator would appear to be vastly underused. There are approximately 41 million women older than 50 years in the United States whose risk for osteoporosis can be rapidly assessed using FRAX, which may then be supplemented with a dual-energy x-ray absorptiometry scan. Statistical illiteracy among physicians may in part be to blame for underuse of quantitative calculators, even for those like FRAX that almost certainly could help direct costeffective primary preventive therapies. It would seem prudent to forestall systemic application of new quantitative risk calculation for preventive intervention–related decision making in cardiovascular disease until there is supportive evidence of benefit to patients in controlled trials. Until then, straightforward cholesterol target guidelines may be best. Alan P. Zelicoff, MD Author Affiliation: Department of Environmental and Occupational Health, College for Public Health and Social Justice, St Louis University, St Louis, Missouri. Corresponding Author: Alan P. Zelicoff, MD, Department of Environmental and Occupational Health, College for Public Health and Social Justice, St Louis University, 3545 Lafayette Ave, St Louis, MO 63118 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Stine NW, Chokshi DA. Elimination of lipid levels from quality measures: implications and alternatives. JAMA. 2014;312(19):1971-1972. 2. Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women’s Health Study. JAMA Intern Med. 2014;174(12):1964-1971. 3. Allan GM, Nouri F, Korownyk C, Kolber MR, Vandermeer B, McCormack J. Agreement among cardiovascular disease risk calculators. Circulation. 2013;127 (19):1948-1956.
(Reprinted) JAMA March 3, 2015 Volume 313, Number 9
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/22/2015
971
