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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article presents the current management of patients with chronic coronary artery disease (CAD) by highlighting key concepts from the 2012 Guidelines for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease [Fihn SD et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012]. The guidelines include detailed algorithms for diagnosis, risk assessment, guideline-directed medical therapy (GDMT), and revascularization to improve symptoms. The discussion continues with suggestions on how the 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension [Drozda J Jr et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011] could provide some insight into the direction of the new guidelines.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology Guidelines\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EExclusive Article - For home page\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EStephan D. Fihn, MD, MPH, University of Washington, Seattle, Washington, USA, discussed the current management of patients with chronic coronary artery disease (CAD) by highlighting key concepts from the 2012 Guidelines for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease [Fihn SD et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2012]. The guidelines include detailed algorithms for diagnosis, risk assessment, guideline-directed medical therapy (GDMT), and revascularization to improve symptoms.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe key concepts from the guideline include the following:\u003C\/p\u003E\u003Cp\u003E\n         \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-5\u0022\u003E\u25aa Management of stable ischemic heart disease (SIHD) should be based on strong scientific evidence and patient preference.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-6\u0022\u003E\u25aa Patients presenting with angina should be categorized as stable versus unstable. Those at moderate or high risk should be treated emergently for acute coronary syndrome.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-7\u0022\u003E\u25aa A standard exercise test is the first choice to diagnose IHD for patients with an interpretable electrocardiogram (ECG) and the ability to exercise, especially if the likelihood is intermediate (10% to 90%).\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003E\u25aa Those who have an uninterpretable ECG and are able to exercise should undergo an exercise stress test with nuclear myocardial perfusion imaging (MPI) or echocardiography, particularly if likelihood of IHD is \u0026gt;10%.\u003C\/p\u003E\n               \u003Cp\u003E\n                  \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n                        \u003Cp id=\u0022p-10\u0022\u003E\u00bb If unable to exercise, MPI or echocardiography with pharmacologic stress is recommended.\u003C\/p\u003E\n                     \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n               \u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n               \u003Cp id=\u0022p-11\u0022\u003E\u25aa Patients diagnosed with SIHD should undergo assessment of risk for death or complications.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-7\u0022\u003E\n               \u003Cp id=\u0022p-12\u0022\u003E\u25aa For patients with an interpretable ECG and who the ability to exercise, a standard exercise test is also the preferred choice for risk assessment.\u003C\/p\u003E\n               \u003Cp\u003E\n                  \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-3\u0022\u003E\u003Cli id=\u0022list-item-8\u0022\u003E\n                        \u003Cp id=\u0022p-14\u0022\u003E\u00bb Those who have an \u003Cem\u003Eun\u003C\/em\u003Einterpretable ECG and are able to exercise should undergo an exercise stress with nuclear MPI or echocardiography, while for those patients unable to exercise, a nuclear MPI or echocardiography with pharmacologic stress is recommended.\u003C\/p\u003E\n                     \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n               \u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-9\u0022\u003E\n               \u003Cp id=\u0022p-15\u0022\u003E\u25aa Patients with SIHD should generally receive a \u201cpackage\u201d of GDMT that includes lifestyle interventions and medications shown to improve outcomes. This includes the following (as appropriate):\u003C\/p\u003E\n               \u003Cp\u003E\n                  \u003C\/p\u003E\u003Cul class=\u0022list-simple \u0022 id=\u0022list-4\u0022\u003E\u003Cli id=\u0022list-item-10\u0022\u003E\n                        \u003Cp id=\u0022p-17\u0022\u003E\u00bb Diet, weight loss, and regular physical activity;\u003C\/p\u003E\n                     \u003C\/li\u003E\u003Cli id=\u0022list-item-11\u0022\u003E\n                        \u003Cp id=\u0022p-18\u0022\u003E\u00bb if a smoker, smoking cessation;\u003C\/p\u003E\n                     \u003C\/li\u003E\u003Cli id=\u0022list-item-12\u0022\u003E\n                        \u003Cp id=\u0022p-19\u0022\u003E\u00bb aspirin 75 to 162 mg daily;\u003C\/p\u003E\n                     \u003C\/li\u003E\u003Cli id=\u0022list-item-13\u0022\u003E\n                        \u003Cp id=\u0022p-20\u0022\u003E\u00bb a statin medication in moderate dosage;\u003C\/p\u003E\n                     \u003C\/li\u003E\u003Cli id=\u0022list-item-14\u0022\u003E\n                        \u003Cp id=\u0022p-21\u0022\u003E\u00bb if hypertensive, antihypertensive medication to achieve a blood pressure (BP) \u0026lt;140\/90 mm Hg; and\u003C\/p\u003E\n                     \u003C\/li\u003E\u003Cli id=\u0022list-item-15\u0022\u003E\n                        \u003Cp id=\u0022p-22\u0022\u003E\u00bb if diabetic, appropriate glycemic control.\u003C\/p\u003E\n                     \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n               \u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-16\u0022\u003E\n               \u003Cp id=\u0022p-23\u0022\u003E\u25aa Patients with angina should receive sublingual nitroglycerin and a \u03b2-blocker. When these are not tolerated or are ineffective, a calcium-channel blocker or long-acting nitrate may be substituted or added.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-17\u0022\u003E\n               \u003Cp id=\u0022p-24\u0022\u003E\u25aa Coronary arteriography should be considered for patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-18\u0022\u003E\n               \u003Cp id=\u0022p-25\u0022\u003E\u25aa The relatively small proportion of patients who have \u201chigh-risk\u201d anatomy (eg, \u0026gt;50% stenosis of the left main coronary artery), revascularization with coronary artery bypass grafting should be considered to potentially improve survival. Most data showing improved survival with surgery compared with medical therapy are several decades old and based on surgical techniques and medical therapies that have advanced considerably. There are no conclusive data demonstrating improved survival following percutaneous coronary intervention.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-19\u0022\u003E\n               \u003Cp id=\u0022p-26\u0022\u003E\u25aa Most patients should have a trial of GDMT before considering revascularization to improve symptoms. Deferring revascularization is not associated with worse outcomes.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-20\u0022\u003E\n               \u003Cp id=\u0022p-27\u0022\u003E\u25aa Prior to revascularization to improve symptoms, coronary anatomy should be correlated with functional studies to ensure lesions responsible for symptoms are targeted.\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-21\u0022\u003E\n               \u003Cp id=\u0022p-28\u0022\u003E\u25aa Patients with SIHD should be carefully followed to monitor progression of disease, complications, and adherence (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-22\u0022\u003E\n               \u003Cp id=\u0022p-29\u0022\u003E\u00bb Exercise and imaging studies should generally be repeated only when there is a change in clinical status (not annually).\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\u003Cp\u003E\n      \u003C\/p\u003E\u003Cp id=\u0022p-30\u0022\u003EThe Scientific Statement from the American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and the American Society of Hypertension (ASH) on the Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease is expected for publication later this year (2013). A prepublication embargo prevented discussion at this year\u0027s annual ACC meeting. Suzanne Oparil, MD, University of Alabama at Birmingham, Birmingham, Alabama, USA, suggested that the 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension [Drozda J Jr et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2011] could provide some insight into the direction of the new guidelines. Specifically, she noted that the 2011 measures go beyond targeting established BP goals. The goal of antihypertensive treatment in patients with CAD or at high cardiovascular disease (CVD) risk was defined as \u0026lt;140\/90 mm Hg. The rationale behind this change from a prior goal of \u0026lt;130\/80 mm Hg was that some clinical trials in which specific antihypertensive drug therapies were given to individuals with CAD or high CVD risk who had BP \u0026lt;140\/90 mm Hg showed benefit, but others had negative or equivocal findings. This heterogeneity in the published literature was used to justify a less strict (\u0026lt;140\/90 mm Hg) BP goal in the performance measures. While the authors acknowledge that lower BP targets may be appropriate for some patients with CAD or other conditions, it is unclear how such patients could be reliably identified for purposes of performance measurement. In Dr. Oparil\u0027s opinion, the strongest evidence in support of the concept that \u201clower is not better\u201d is the ACCORD trial, which showed no benefit from intensive (\u0026lt;120 mm Hg) versus standard (\u0026lt;140 mm Hg) BP control in terms of fatal and nonfatal major CV events in patients with type 2 diabetes at high risk for CV events [ACCORD Study Group. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. Subanalyses and post hoc reports from the INVEST [Cooper-DeHoff RM et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2010] and ONTARGET trials [Mancia G et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011] provide similar findings. Although the Systolic Blood Pressure Intervention Trial [SPRINT; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT01206062\u0026amp;atom=%2Fspmdc%2F13%2F2%2F8.atom\u0022\u003ENCT01206062\u003C\/a\u003E] will likely not end until 2016 or later. Dr. Oparil said the results are highly anticipated as it is designed to assess the effects of intensive BP lowering (\u0026lt;120 vs \u0026lt;140 mm Hg) on major CV events in patients without diabetes but with CVD risk factors, including chronic kidney disease, clinical CVD (excluding stroke), and age \u0026gt;75 years.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/13155\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/13155\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13155\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-31\u0022 class=\u0022first-child\u0022\u003ENoninvasive Testing in Known SIHD\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-40\u0022\u003EAs with the 8\u003Csup\u003Eth\u003C\/sup\u003E report on the Joint National Commitee on Prevention, Detection, Evaluation and Treatment of Hypertension (JNC8), the Guidelines for the Management of High Blood Pressure in Adults \u2013 JNC 2013, the new guidelines for treating lipids in patients at risk for CVD (Adult Treatment Panel; ATP IV) are also still in development. In lieu of a discussion of the guidelines, Jennifer G. Robinson, MD, MPH, University of Iowa, Iowa City, Iowa, USA, discussed new evidence published since the committee completed their work and some of the evidence considered in the development of the guidelines. Of recent interest are the results of a meta-analysis of 27 primary and secondary prevention trials (n=134,537 participants) that evaluated the effects of using statins to lower low-density lipoprotein cholesterol (LDL-C) in individuals at low risk of CVD [Cholesterol Treatment Trialists\u0027 Collaborators. \u003Cem\u003ELancet\u003C\/em\u003E 2012]. A key finding of the study was that for individuals with a 5-year risk of major vascular events of \u0026lt;10% (a population of patients not typically considered suitable for statin therapy), each 1-mmol\/L reduction in LDL-C produced an absolute reduction in major vascular events of approximately 1.1%. In particular, those patients without a history of vascular disease and a 5% to \u0026lt;10% 5-year major CVD risk experienced a significant reduction (34%; p=0.003 for trend) in the relative risk of major CVD and a borderline significant 17% reduction in total mortality compared with those in the higher risk groups (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cp id=\u0022p-41\u0022\u003EThe AHA recently issued a statement on triglycerides and CVD [Miller M et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2011]. Dr. Robinson briefly summarized that statement noting that the focus in patients with triglyceride levels \u0026lt;500 mg\/dL should be on decreasing the risk for CVD through improved diet, increased physical activity, and weight loss, and by getting the patient on a statin. These patients should also be assessed for diabetes. Treatment is the same for patients whose triglyceride level is \u0026gt;500 mg\/dL, but with the additional focus of preventing pancreatitis.\u003C\/p\u003E\u003Cp id=\u0022p-42\u0022\u003EThis session offered some early insights into the long-awaited and eagerly anticipated release of the JNC-8 and ATP IV guidelines.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/8\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Reduction in Major CVD Risk Among Primary Prevention Patients With a 5% to 10% 5-Year Major CVD Risk per 1 mmol Reduction in LDL-C With a Statin\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-180153605\u0022 data-figure-caption=\u0022Reduction in Major CVD Risk Among Primary Prevention Patients With a 5% to 10% 5-Year Major CVD Risk per 1 mmol Reduction in LDL-C With a Statin\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/8\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/8\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/2\/8\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13154\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-43\u0022 class=\u0022first-child\u0022\u003EReduction in Major CVD Risk Among Primary Prevention Patients With a 5% to 10% 5-Year Major CVD Risk per 1 mmol Reduction in LDL-C With a Statin\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECVD=cardiovascular disease; LDL-C=low-density lipoprotein cholesterol; MVE=major vascular events.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from Mihaylova B et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: Meta-analysis of individual data from 27 randomised trials. \u003Cem\u003EThe Lancet\u003C\/em\u003E Aug 2012;380(9841):581\u2013590.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/2\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzo01d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzo01d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzo01d\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}