JOURNAL SNIPPETS

Lancet 4 Sep 2010 Vol 376
784 The palliation of terminal dyspnoea is a subject is interesting, mainly in the context of heart failure, where many patients are dyspnoeic without substantial reduction in oxygen saturation. Nevertheless they frequently get symptomatic benefit from inhaled oxygen, some to the point of becoming dependent on an immediate oxygen source. For years I heard some of the authors of this study discuss a blinded randomised trial of room air versus oxygen for such patients, not just with those with cardiac dyspnoea but with a range of terminal conditions. And here at last it is: a landmark in evidence-based palliative care, showing that room air works as well as oxygen over a period of a week. However, I can foresee major problems in real life: "Are you trying to kill him doctor? They've delivered a cylinder of compressed air, but Eric needs his oxygen. I told them to take it away."
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61115-4/abstract

BMJ 4 Sep 2010 Vol 341
491 A worthy attempt to meta-analyse the data that exist about the outcomes of nurse-led interventions to improve control of blood pressure. Nurses using algorithm-guided protocols show some success in the USA, especially when they are given prescribing powers. But just what are we doing in hypertension? A recent review I read suggested that it really takes 14 office readings to determine whether a change of treatment is needed. Most of what we do to our patients with raised blood pressure is probably futile, and we urgently need better primary care studies to tell us how to do better.
http://www.bmj.com/content/341/bmj.c3995.full

From JOURNAL WATCH

JAMA 2 Dec 2009 Vol 302
2345 Rarely has an issue of JAMA contained so little worth commenting on. I only point your attention to this article on the assessment of claims of improved prediction beyond the Framingham score because our overlords and paymasters sometimes direct us to use such scores, and perhaps some of you actually do. Personally, I seldom bother. Still less do I care about the veracity of claims that additional factors improve the score: and in fact this paper shows that there is scant evidence that they do. The authors don't enter into the Q-RISK debate arena because that's about a separate issue of generalisability to different populations. The fact is that in the NHS every major cardiac risk factor is subject to its separate irrational dictates. Treat all blood pressure if it is above a certain limit. Treat cholesterol only if it part of a risk score. Treat obesity with interventions which have been shown not to work, but not with bariatric surgery, which does work, and usually cures diabetes to boot. Treat smoking with small supplies of nicotine replacement rather than with drugs that have been shown to work much better. And so on. A percentage point or two in some score is never going to bring reason into this chaos.
http://jama.ama-assn.org/cgi/content/abstract/302/21/2345

NEJM 3 Dec 2009 Vol 361
2241 This week's New England Journal is no diamond mine either, but this study of advanced heart failure treated with a continuous-flow left ventricular assist device may be a pointer for the future. At the moment, if one of your patients with advanced HF becomes pulseless, you can predict with considerable certainty that he is dead. But increasingly you will encounter pulseless HF patients walking around alive, each of them carrying a briefcase. This does not contain native soil to allow daytime rest in a coffin, but heavy duty batteries to keep a continuous-flow pump going in the left ventricle. I know one such patient who had his briefcase pinched, but managed to survive. LVADs are still very expensive and fraught with problems, but this study shows that they do help patients with very poor LV function to live on and that they are much better than pulsatile devices.
http://content.nejm.org/cgi/content/abstract/361/23/2241

2261 Mitral valve prolapse is commoner than you think. If Framingham Offspring data are generalisable, then your personal list of 2,000 patients will include no less than 50 with the condition, and of these about 5-7 will eventually develop significant mitral regurgitation. The traditional cure is mitral valve replacement, but this clinical review cites good evidence that mitral valve repair is a better option. There are nice illustrations, as indeed there are in the LVAD paper. It's all rather awe-inspiring and a definite incentive to become a heart surgeon in your next life.
http://content.nejm.org/cgi/content/extract/361/23/2261

BMJ 5 Dec 2009 Vol 339
I continue to follow the literature about salt and cardiovascular disease with a furrowed brow. This is not quite science as I understand it. The interventional studies are weak. The whole-population observational studies are painstaking but their measurement methods are poor and there is endless room for confounding. Proponents of the salt hypothesis (see editorial) sometimes resort to quasi-religious discourse about WHO targets and the Neolithic diet, i.e. a mixture of authority and ignorance. We might do better to state simply that salt is a modifiable factor which we would probably benefit from modifying, whether the central theory is true or not, since we have no way of knowing. A bit like climate change, which The Lancet discusses this week.
http://www.bmj.com/cgi/content/full/339/nov24_1/b4567

Upcoming conferences 2009

Cardiac Conference
Location:5 Lakes Golf and Country Club
Date(s):13 May 2009
Time(s):9:45am to 4:30pm
Topics to be covered include
© Cutting Edge of Cardiac Surgery
© Lifestyle / Obesity and Cardiac Risk
© The Irregular Pulse and Atrial Fibrilation (AF)
© Primary Angioplasty
© GUCH
© Simply ECGs………… workshop
© By popular demand – Interactive workshop, infant child and adult resuscitation skills
© Cases We Learnt Most From

For full details click on link
http://www.essexcardiacservices.nhs.uk/page.asp?node=5&action=view_event&tid=917&sec=Events___Meeting_Dates


Public Stroke Awareness Conference
Essex Cardiac and Stroke Network invite you to a Stroke Awareness conference for any Essex residents to find out more about stroke and stroke prevention.
The day will cover topics like:

• What is a transient ischaemic attack (TIA) - mini stroke or stroke
  Stroke types - clot or bleed, when & why clot busting drugs are used
  Patient experience
  Stroke services across Essex
  The role of The Stroke Association
  East of England Ambulance Service (using the FAST method)
  What dysphasia means to a stroke survivor
  Health promotion and prevention - lifestyle advice

Display stands to browse and collect information
– A full agenda to follow once finalised.
Event Information
Location:5 Lakes Golf and Country Club
Date(s):17 June 2009
Time(s):10am to 4pm
Documents:
Public Stroke Awareness Conference Flyer(131Kb

FISH OIL

Effect of fish oil on arrhythmias and mortality: systematic reviewLeon H, Shibata M C, Sivakumaran S, Dorgan M, Chatterley T, Tsuyuki R T

CRD summary
This review investigated the effects of fish oil on mortality and arrhythmias. The authors found that fish oil supplementation was associated with a significant reduction in deaths from cardiac causes but was not beneficial for arrhythmic events or all-cause mortality. The authors' conclusions reflected the results but the reliability of these is unclear given heterogeneity between studies and unclear reporting.
Authors' objectives
To investigate the effects of fish oil – docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) – on mortality and arrhythmias and to explore dose response and formulation effects.
Searching
Several sources including MEDLINE, EMBASE, The Cochrane Library, PubMed, CINAHL, Web of Science and ProQuest Dissertations and Theses were searched in 2006 without language restrictions (search dates varied, spanning 1966 to 2006). Search terms were reported. Heart disease and omega 3 fatty acid papers from the IBIDS database and reference lists of included studies were also examined to identify additional studies. An update search was performed in March 2007.
Study selection
Randomised controlled trials (RCTs) in which fish oil was investigated as a dietary supplement were eligible for inclusion. Trials that included pregnant women or children, or those that lasted less than three months were excluded. The following outcomes were eligible for inclusion: arrhythmic end points of appropriate implantable cardiac defibrillator intervention (confirmed by electrogram); sudden cardiac death (primary outcomes); all cause mortality and death from cardiac causes (secondary outcomes).
The included studies were conducted in a variety of patient populations (for example, implantable cardiac defibrillation, after percutaneous coronary angioplasty and acute myocardial infarction patients). The mean age of the treatment group ranged from 48.5 to 66.2 years and the control group 49.2 to 65.3 years. The doses of EPA ranged from 18.2 - 2,800mg/day and DHA 0 - 2,340mg/day. The control also varied. Follow-up ranged from 1 to 60 months.
Two reviewers independently selected studies and a third reviewer acted as mediator should discrepancies occur.
Validity assessment
Methodological quality was determined using a form derived from the Jadad scale (which assesses features such as randomisation, blinding and withdrawals to give a quality score out of 5). Additional quality criteria were assessed, such as concealment of treatment allocation, funding agencies and use of intention to treat (ITT) analysis.
Validity was assessed independently by two reviewers
Data extraction
The outcomes of interest were extracted to calculated odds ratios (ORs) and corresponding 95% confidence intervals (CIs) by two independent reviewers. A third reviewer mediated in the event of discrepancies.
Methods of synthesis
ORs were pooled in a random effects meta-analysis (DerSimonian and Laird method) and presented as odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the Χ2 test and I2 test. Overall effect was determined by the z test. A meta-regression analysis of deaths from cardiac causes was carried out using a random-effects model to investigate any dose-response effect. Relative risk of non-cardiovascular adverse effects was evaluated. Treatment effects and adverse effects were expressed as number needed to treat (NNT) and number needed to harm (NNH). A funnel plot was used to assess publication bias.
Results of the review
Twelve RCTs were included in the review (n=32,779). Two large trials (n=29,979) provided the majority of participants. Five studies had a quality score of 5/5, four studies 4/5, two studies 3/5 and one study 2/5.
Supplementation with fish oil was associated with a statistically significant (20 per cent) decrease in death from cardiac causes (11 RCTs, n=32,519) OR 0.80 (95% CI: 0.69, 0.92, p=0.002). There was evidence of publication bias but no evidence of significant statistical heterogeneity.
In a subgroup of patients with coronary artery disease or after myocardial infarction fish oil supplementation was associated with a statistically significant (26 per cent) reduction in sudden cardiac death compared with control (four RCTs, n=15,528) OR 0.74 (95% CI: 0.59, 0.92, p=0.008), and a statistically significant (20 per cent) reduction in death from cardiac causes compared with control (eight RCTs, n=16,390) OR 0.80 (95% CI: 0.69, 0.93, p=0.004). No statistically significant heterogeneity was detected.
Adverse effects occurred in 10.5 per cent of patients who took fish oil compared with 6.7 per cent of control patients. Most of the effects were described as mild. The NNT to prevent one cardiac death was 189 and the NNH was 26.
Fish oil supplementation was not associated with a significant reduction in the risk of appropriate implantable cardiac defibrillator intervention or the incidence of sudden cardiac death (the primary outcomes) or all cause mortality. No dose-response relationship was found between DHA and EPA and death from cardiac causes.
Authors' conclusions
Fish oil supplementation was associated with a significant reduction in deaths from cardiac causes, but is was not beneficial in terms of arrhythmic events or all-cause mortality.
CRD commentary
The review question was clear and there were inclusion criteria for study design, intervention, participants and outcomes. The authors searched published sources and studies reported in any language were sought, which reduced the possibility of language bias. No attempt to identify unpublished studies was reported, increasing the possibility of publication bias. Validity of the primary studies appeared to be assessed appropriately. Study selection, validity assessment and data extraction were performed independently by two reviewers, minimising the risk of reviewer bias and error. Statistical heterogeneity and publication bias were assessed and taken into consideration by the authors. Given the clinical heterogeneity of the studies in terms of participants and intervention, pooling of these studies may not have been appropriate. The results of the review were driven by two very large trials. One study with one month follow-up was included despite this being less than the specified inclusion criteria for follow-up. The authors' conclusions reflected the results, but the reliability of these is unclear given the clinical differences between studies.
Implications of the review for practice and research
Practice: the authors stated that it would be reasonable to use a daily formulation of 465 mg EPA/386mg DHA (similar to that of the GISSI-Prevenzione trial).
Research: the authors did not state any implications for research.
Funding
Not stated
Bibliographic detail
Leon H, Shibata M C, Sivakumaran S, Dorgan M, Chatterley T, Tsuyuki R T. Effect of fish oil on arrhythmias and mortality: systematic review. BMJ 2008; 337(a2931)
URL for original research
http://www.bmj.com/cgi/reprint/337/dec23_2/a2931
Subject index terms status
Subject indexing assigned by CRD
Subject index terms
Arrhythmias, Cardiac; Cardiovascular Diseases; Dietary Supplements; Docosahexaenoic Acids; Eicosapentaenoic Acid; Fatty Acids, Omega-3; Fish Oils; Humans
Accession number
12008107698
Database entry date
7 April 2009
Record status
This record is a structured abstract produced by CRD. It is based on the paper BMJ and the additional information available on the BMJ website. The original has met a set of quality criteria. Since September 1996 abstracts have been sent to authors for comment. Additional factual information is incorporated into the record. Noted as [A:....].
Database of Abstracts of Reviews of Effects (DARE)Produced by the Centre for Reviews and DisseminationCopyright © 2008 University of York.

HSJ article

New plan for cardiac and vascular disease
Published: 12 March 2009 15:36
Author: Betty McBride
More by this Author
Last Updated: 12 March 2009 15:36
Reader Responses

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Cardiac and vascular disease urgently needs a strategy that goes further and wider than the current framework and improves access to high quality services for far more people.
No-one working in health could miss the fact that heart disease has been a priority issue over the past decade. Politicians, health policy makers and NHS managers have given the UK's biggest killer the attention it deserves. The national service framework for coronary heart disease translated this concern into action by taking a root and branch approach to improving prevention, treatment and care of people who have or are at risk of coronary heart disease.
And the plan has worked. Deaths due to heart disease have fallen by more than 40 per cent - an impressive five years earlier than the framework planned for. Waiting times for heart surgery are down. Numbers of consultant cardiologists are up.
Prevention is also improving, with tobacco control measures helping to cut the number of smokers. And incentives encouraging GPs to prescribe statins - and the availability of these drugs over the counter - mean millions of people are at lower risk of furred arteries.
"The cardiovascular community wants a plan not just for heart and disease but for related conditions"
The government has rightly taken credit for these major achievements. The Department of Health has been happy with progress, sounding a possibly premature victory cry in its 2004 progress report Winning the War on Heart Disease.
But the cardiovascular community is worried. The service framework was published in 2000, so it is fast approaching its sell by date of early 2010 but there are as yet no confirmed plans to replace it.
A lot has been achieved but there is still a lot to do. The death rate may be down, but cardiac and vascular conditions remain the leading cause of death in the UK. And the numbers of people living with these diseases are set to increase as effective treatments and surgery enabling people to survive heart attacks and strokes mean they need ongoing care. The ageing population will only add to this.
The cardiovascular community wants more. Not a replica of the current framework but a plan that goes further and wider, covering not just heart disease but embracing related conditions such as stroke, diabetes, chronic kidney disease, transient ischaemic attacks (mini strokes) and peripheral vascular disease (affecting the blood vessels in the legs and arms). Joined up thinking is crucial because of the many common risk factors across cardiac and vascular disease.
We believe it makes sense to develop a new strategy for cardiac and vascular disease that recognises links and make recommendations to achieve progress across all these conditions.
There are clearly items remaining on the to-do list from the framework that should go straight into the new plan. Rehabilitation can make all the difference between someone who has had a heart attack or stroke getting back to the activities they enjoyed before they became ill or being limited by ongoing disability.
Wider strategy
The framework promised cardiac rehabilitation would be available to 85 per cent of heart patients by 2002, but a recent national audit of cardiac rehabilitation warned that around 60 per cent of the patients who need it are denied the chance of taking part and many programmes are unable to meet clinical guideline standards. A new strategy needs to draw on the experience gained, setting out what excellence looks like and providing the resources needed.
End of life care is an area that needs more work. Huge progress has been made in improving the care of people dying with cancer. But people dying of cardiac and vascular conditions often miss out on specialised palliative care.
"Parts of the DH whisper that developing a new strategy across all cardiovascular diseases is a Herculean task"
Concern is so great that the cardiovascular community has come up with an unprecedented response and a recommended plan of its own. Destination 2020: a plan for cardiac and vascular health - a voluntary sector vision for change - will be launched later this month.
These recommendations have been developed by the Cardiac and Vascular Coalition: 41 voluntary and professional organisations with an interest in promoting cardiac and vascular health in England. They represent the voices of patients, carers and health professionals - experts with an understanding of how to tackle cardiovascular disease on the front line.Parts of the DH whisper that developing a new strategy across all cardiovascular diseases is a Herculean task. Yet politicians across all political parties have met and engaged with the coalition project and our vision for change. We are confident politicians and health policy makers will listen and act on our recommendations, which serve the interests of millions of patients.
Author: Betty McBride.Betty McBride is policy and communications director at the British Heart Foundation and chair of the Cardiac and Vascular Coalition.