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In Reply: Drs Abumrad and Barbul note that prestudy and 6-month plasma arginine levels were similar in the placebo and active therapy groups. Although poor adherence is one possible explanation, pill counts at 1 month, 3 months, and 6 months indicate otherwise. We suggested that in this cohort with normal baseline arginine levels, up-regulation of enzymes responsible for arginine catabolism, as described by Morris¹ and Castillo et al,² is a more likely mechanism. The product we used was L-arginine hydrochloride, produced with a good manufacturing practice label.

We disagree with the characterization of the mortality rates in our study. In planning the study, we estimated a 10% mortality risk over 6 months in patients aged 60 years and older based on review of the literature.^3-4 The mortality in our study was lower than anticipated: 7.8% over 6 months in those patients aged 60 years and older and 3.9% for . . . [Full Text of this Article]

Steven P. Schulman, MD
sschulma@jhmi.edu

Gary Gerstenblith, MD
Division of Cardiology
Johns Hopkins University School of Medicine
Baltimore, Md

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