SNIPPETS FROM JOURNAL WATCH

Lancet 19 Jun 2010 Vol 375
2161 Golly - here's something you don't often see in The Lancet: a trial puffing a new drug for angina which costs about £20 per year. Nor is it subsidised and ghost-written by the drug's manufacturers, who have probably long ago lost interest in it. Because the drug is our old friend allopurinol, at 600mg daily, used to improve exercise tolerance in ischaemic heart disease as opposed to preventing gout. It's a very small short-term trial, but there seems to be no reason not to give the drug a go - and quite a few reasons to believe that it may be a good thing for the strained myocardium (see editorial on p.2126).
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60391-1/abstract

JAMA 9 Jun 2010 Vol 303
2280 "Does This Patient Have a Haemorrhagic Stroke?" asks the latest in The Rational Clinical Examination Series. "How should I know, I haven't seen the scan" might be the usual answer, and it also turns out to be the correct one. Features like coma, headache, neck stiffness and high blood pressure all make haemorrhage a bit more likely, but the only way to know with sufficient certainty is by putting the patient through a CT scanner, preferably within the window for thrombolysis if the stroke turns out to be ischaemic. This is confirmed by 19 prospectively studies, meticulously analysed here.
http://jama.ama-assn.org/cgi/content/abstract/303/22/2280

NEJM 10 Jun 2010 Vol 362
2155 This study is based on the Kaiser Permanente insured population of California and it tells a pretty amazing tale - ST elevation myocardial infarction has fallen by 62% in the last decade. Interestingly the incidence of non-ST elevation MI went up between 2002 and 2004 as troponin assays became widely adopted as the diagnostic gold standard, but even taking this into account, the incidence of any MI has gone down by a third. During this time, Californians became a bit fatter, did slightly more exercise, were banned from smoking in public places, and were prescribed more statins, beta-blockers and ACE inhibitors. We are not told if they drank more of their sometimes passable wines.
http://content.nejm.org/cgi/content/abstract/362/23/2155

Lancet 12 Jun 2010 Vol 375
2073 From the point of view of someone fixated on the cardiovascular system, the body consists of a central pump supplying blood to various tufts - lung-tufts to oxygenate it, gut-tufts to feed it and kidney tufts to get rid of waste products, and so on. I can see that for some the kidney is an interesting organ, but it's essentially a dangling footnote to the business of assessing cardiovascular risk, and delicious when prepared correctly. Now assessing risk (or prognosis) is itself of little importance unless you can use it to guide interventions to reduce risk. All of which makes it very frustrating to wade through a paper like this which pools data from 14 studies (over 100 000 individuals) to derive risk tables for all-cause and cardiovascular mortality graded by eGFR and albuminuria, independently of blood pressure, cholesterol and smoking. There seems to be a definite association which, surprisingly, is slightly U-shaped when you combine the two factors. So was QOF right to make us identify and check out everyone with an eGFR under 60? That's another question entirely, which depends on how much these factors contribute to total CV risk, and what we can do about it.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60674-5/abstract

JAMA 2 Jun 2010 Vol 303
2141 Acute heart failure is regarded by most members of the public as synonymous with death, and indeed a proportion of patients admitted to hospital with HF do die within 30 days, but this stands at barely more than one in ten, and has hardly changed between 1993 and 2006, dropping from 12.8% to 10.7%. During that time, nearly 7 million Americans covered by Medicare have been to hospital with acute HF, and very little else has changed either: they get discharged a bit sooner, and readmitted slightly more often. A huge, meticulous, well-described outcomes study of this kind inevitably has one looking for Harlan Krumholz; yes, there he is.
http://jama.ama-assn.org/cgi/content/abstract/303/21/2141

2148 The heart failure figures are rather disappointing, whichever way you spin them; but one definite way to reduce HF is to save myocardium by timely reperfusion therapy for acute myocardial infarction. We know this from many interventional trials, of course, but given the immense organisational effort that has gone into providing access to immediate percutaneous intervention for MI, it is nice to have observational evidence from a large population too. Voici QuÃÆ'Ã" '©bec. In 2006-7, nearly 80% of quÃÆ'Ã" '©bÃÆ'Ã" '©cois with ST elevation MI received PCI, but in 68% of cases this occurred after more than 90 minutes. If you look at a map of Canada, you will see why: the province is more than twice the size of France and stretches up and beyond the Arctic Circle. Of those who received thrombolysis, 54% got it later than the ideal 30 minutes. The mortality figures following the two modes of treatment are remarkably similar, but outcomes such as recurrent MI and the need for bypass grafting favour PCI. By contrast, the treatment within the ideal window halves your chance of death within 30 days.
http://jama.ama-assn.org/cgi/content/abstract/303/21/2148

BMJ 5 Jun 2010 Vol 340
1231 The star of this week's BMJ is Julia Hippisley-Cox, professor of primary care in Nottingham, who has used the EMIS database of British general practices to derive an improved cardiovascular risk score (QRISK) and has also (see below) worked out from it what the true risks and benefits of statins are in UK primary care. We are lucky to have such studies to refine our practice, since they apply directly to the population we treat. As she has been working on the two versions of QRISK, Gary Collins and Doug Altman have been dogging her footsteps, and here they publish an independent and external validation of QRISK2. Use it with confidence in British general practice - you won't get a better Good Housekeeping Seal of Approval than this.
http://www.bmj.com/cgi/content/full/340/may13_2/c2442

1233 Allan Struthers has done much of the basic work on BNP and the renin-angiotensin pathway. The end product of this pathway is aldosterone, and the Dundee-led RALES trial published in 1999 showed that by blocking it with spironolactone in patients with chronic heart failure, you could improve outcomes even if they were on other RAS-inhibiting treatments. So off I went and gave some to a few of my HF patients, noting that the RALES trial encountered few problems with hyperkalaemia. I duly checked the electrolytes of one patient a couple of weeks later and sent him straight to hospital with a potassium of 6.8. This alarming event proved to be common enough in Canada, too, according to a paper which appeared in the New England Journal in 2004. But here Allan Struthers et al rebut their critics with data from Tayside, proving that your canny Scots GP can use sprironolactone with perfect safety, laddie, aye perfect safety. As the great poet of the Tay might have put it :Physicians of England and Canada kill their patients with hyperkalaemia; But by the banks of the silvery Tay our doctors behave much more seemlier. W. McGonagall op posth.
http://www.bmj.com/cgi/content/full/340/may18_2/c1768

SNIPPETS FROM JOURNAL WATCH

JAMA 3 Feb 2010 Vol 303
If the Good Death Cookbook ever gets compiled from the recipes from Journal Watch, the evidence linking dietary sodium with cardiovascular disease outcomes needs to be confronted. All of it is observational; and according to this article, the studies are in equipoise. That's right: there are some studies showing cardiovascular harm from lowered salt intake; most are neutral; some show benefit. But there has never been a prospective randomised trial.
http://jama.ama-assn.org/cgi/content/extract/303/5/448

BMJ 6 Feb 2010 Vol 340
It's a convenient belief, supported by some systematic reviews of randomised trials, that all blood pressure lowering regimens are equally beneficial in proportion to the degree to which they succeed in reducing BP. This population based case-control study seeks to dispute that, and in particular to blacken the name of calcium-channel blockers compared to ACE inhibitors and ARBs. Again, you won't learn much from the one-page version. In the full on-line article, you can see the confidence intervals in all their unconvincing glory. There may be some differences, but we need better evidence than this.
http://www.bmj.com/cgi/content/full/340/jan25_2/c103
One of the reasons of the Easily Missed series was to find out what I had been missing these last thirty-five years. Long QT syndrome is a definite case in point. If you have a young patient who has fainted during exertion or on being woken by a loud noise, get an ECG at once and make sure it is looked at carefully: the next episode may be sudden death.
http://www.bmj.com/cgi/content/extract/340/jan08_1/b4815

Ann Intern Med 2 Feb 2010 Vol 152
Just as you wouldn't give up and blame the patient if their blood pressure remained at 186/112 despite a short course of treatment, so you mustn't give up treating nicotine addiction until people no longer run the awful cardiovascular and pulmonary risks of smoking. Give them nicotine replacement therapy for as long as it takes, and bin any guidelines which instruct you to do otherwise on grounds of cost. This study unsurprisingly found that a nicotine patches are more effective prescribed for 24 weeks than for 8. Many smokers won't need this length of treatment, others will need more.
http://www.annals.org/content/152/3/144.abstract
Non-invasive coronary angiography sounds like a great idea, but there are problems. Magnetic resonance imaging would be ideal if it worked, because it doesn't involve ionizing radiation. But this head on comparison with computed X-ray tomography shows that it is not nearly as accurate, according to the published studies. This may change as techniques develop, of course. The problem with CT is that it uses big doses of radiation and needs iodine-base contrast material; and so does the gold standard of coronary angiography, which the patient will then have to undergo if the CT shows a lesion requiring intervention. The real-life radiation dosage studies are worrying, though every article predicts that doses will fall in the future.
http://www.annals.org/content/152/3/167.abstract

24/7 THROMBOLYSIS FOR STROKES

Tuesday 6 October 2009 saw the launch of the 24/7 thrombolysis service for patients at Basildon and Thurrock University Hospital, due to the appointment of 2 new consultants, the support of the Cardiac and Stroke network and partnership working with the Stroke Rehab Unit, Radiology and NHS South West Essex. Pasteur ward is now a dedicated acute stroke unit.
Not all patients are suitable for the treatment as it depends on the severity and cause of the stroke, whether by a bleed or blood clot. Assessments, including a CT scan, have to be carried out before treatment.
The drug is only licenced for patients between 18 and 80 and they have to be thrombolysed within 3 hours of the first sign of a stroke. The drugs minimise the damage caused to the brain and helps prevent lasting disabilities by dissolving the blood clot.
It is hoped the service will go from strength to strength.