JOURNAL SNIPS

NEJM 1 Oct 2009 Vol 361
1329 Cardiac resynchronisation therapy (dual chamber pacing) is a good intervention for about two thirds of patients with heart failure due to systolic dysfunction. We’ve known that for a while, and it’s worth repeating because it’s an under-used treatment in the UK and one that’s worth fighting for in a time of financial restraint. Implantable cardioverter-defibrillators, on the other hand, are of dubious value to most heart failure patients, especially women, and at the end stage prevent sudden painless death at the shocking (literally) cost of repeated firings and drowning from pulmonary oedema. So I have grave misgivings about the design of this trial to prevent overt heart failure in patients with minimal breathlessness but severely impaired systolic function, either due to ischaemia or non-ischaemic cardiomyopathy. They were relatively young (mean 64) and nearly asymptomatic despite having a mean LVEF of 24%. They were all fitted with ICDs; half of them also with dual chamber pacemakers. The trial was stopped early as the paced group had 41% fewer episodes of overt heart failure. These are not the kind of heart failure patients you see much of in primary care, so it doesn’t get us all that far. However, it’s consistent with my headline message: think biventricular pacing for all your appropriate real-life HF patients, think ICD for very few. http://content.nejm.org/cgi/content/abstract/361/14/1329

1368 One patient I remember was a sculptor who ended an anecdote with the words “I nearly killed him with my bare hands!” The great surgeon moved on, laughing grimly, “I’ve killed plenty of people with my hands”. Hospital mortality associated with inpatient surgery in the USA shows a twofold variation between the lowest and the highest quintiles, which surprisingly is not related to complication rates. Rather it is related to the way complications are managed. Surgeons, it seems, kill more patients after their operations than during. http://content.nejm.org/cgi/content/abstract/361/14/1368

Lancet 3 Oct 2009 Vol 374
1171 Of all the things to UPLIFT sales for Boehringer Ingelheim and Pfizer Pharmaceuticals, a disease-modifying agent for chronic obstructive pulmonary disease would have to come top. They ran a trial of this name for tiotropium in various grades of COPD, carefully prespecifying their subgroups so they could not be accused of cheating if one of them turned out to have a good result. In patients with stage II COPD using the GOLD classification this proved to be the case – a reduction in decline of postbronchodilator FEV1 and better ratings on the St George’s Respiratory Questionnaire compared with placebo. So for patients with early and mild symptoms, tiotropium may have a place. But whether this really warrants a population-wide effort to identify early COPD, as the editorial states, is more debatable. There is still a lot more to be done in promoting smoking cessation, the only intervention that will really affect COPD, plus cardiovascular disease, plus lung cancer; and a lot else.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61298-8/abstract