JOURNAL SNIPPETS JAN 11

JAMA 12 Jan 2011 Vol 305
167 Single combat between mounted Mongolian warlords, and arguments between cardiac surgeons - these are spectator sports which it is best not to stand too close to. It is an article of faith that in coronary bypass operations, radial artery grafts always outperform saphenous vein grafts. Here is a study with 36 authors to show that there is no difference in patency at one year. Gentlemen, get down from your horses, please: some of these guys are Texans.
http://jama.ama-assn.org/content/305/2/167.abstract

175 We need to know more about the effect of the drugs we use for heart failure in the general mix of patients we treat in the community. The randomised controlled trials tell us a lot about specific drugs, usually when added to standard treatments in selected populations, but this may be an area where observational studies done on typical populations are just as valuable. That said, certainty is never going to be on offer, given the difficulties of defining the diagnosis and the impossibility of eliminating confounders: there is no such thing as heart failure without co-morbidity. So two cheers for this Swedish population database study which tried, but did not altogether succeed, in matching two groups of heart failure patients who took losartan or candesartan, and tracking their mortality over five years. Those taking candesartan showed better survival. It would be nice to do a similar comparison using the UK GP Research Database, but they have just made that harder by withdrawing free access.
http://jama.ama-assn.org/content/305/2/175.full

JAMA 5 Jan 2011 Vol 305
43 Implantable cardioverter-defibrillators are a good intervention for those who have bad systolic heart failure with a risk of ventricular arrhythmia, and would rather die slowly than suddenly. The "utility" of the device is that it can have a statistically significant effect on mortality in younger, properly selected patients; the "dysutility" includes everything that can go wrong with the machines and the possibility that dying from pump failure may be accompanied by multiple painful electric shocks. As you'll gather, I'm not a great fan of these devices, but most cardiologists are. In the USA, their use by Medicare and Medicaid was approved in 2005, since when a registry has been kept, and this study examines it to find out how many ICD implantations were not evidence-based. Using agreed criteria, the answer is about 22.5%, meaning that between a fifth and a quarter of all ICDs cannot be expected to do any good to the patient, while the potential for harm is considerable. I wonder what kind of informed, shared decision-making goes on before these things are inserted into people?
http://jama.ama-assn.org/content/305/1/43.abstract

NEJM 6 Jan 2011 Vol 364
11 Here's a classic pharma-funded trial of eplerenone in systolic heart failure with mild symptoms: EMPHASIS-HF. Pfizer paid for patients to be recruited in 278 centres in 29 countries, with fewer than 10 patients per centre; their mean age was 69, with none reaching 76, the mean age of heart failure patients in the community; and 78% of them were male. The trial was stopped prematurely when the eplerenone group showed a large reduction in the composite end-point of death and readmission. So we know that the drug works for this group of patients, though the effect size and long term effects cannot be known accurately due to early termination. We have no idea what the drug does for symptoms, since these weren't considered. We don't know what its effects will be on older patients with comorbidities, or on patients with heart failure and a normal ejection fraction. It will probably cause much more serious hyperkalaemia in the community than in the trial, as was the case with spironolactone following the RALES study. Sales of eplerenone will soar in its last few years on patent, and the heart failure community will be happy that its academic centres and conferences will have been paid for until the next bonanza comes along. Meanwhile, clinicians will struggle to know what best to do for their patients, especially as a quarter of the patients in this trial had QRS prolongation and should have had biventricular pacing.
http://www.nejm.org/doi/full/10.1056/NEJMoa1009492