NEJM 11 Mar 2010 Vol 362
886 This study looked at nearly 400,000 elective coronary angiographies performed in US hospitals over 4 years. Although preliminary investigations had been done in 84% of cases, the pick-up rate for significant coronary stenosis on angiography was 37.6%. Even these patients may have had little benefit, since COURAGE tells us that in stable angina, people do as well with optimal medical treatment as with percutaneous intervention. So 250,000 of these angiographies were definitely of no value to the patients, and that probably applies to most of the rest too. We need much better case selection for the catheter lab, with all its attendant risks of radiation and bleeding, not to mention cost in money and cardiologist time.
http://content.nejm.org/cgi/content/abstract/362/10/886
906 Thyroxine lowers cholesterol, as most of you will know from treating hypothyroid patients. Statins also lower cholesterol, as most of you will also know: but not always enough for the liking of lipidologists. They and the drug companies are forever in search of the next lipid lowering drug, an easy and potentially lucrative quest based on serum fat measurements of various kinds, as in this study of eprotirome, a thyromimetic compound. My word, it lowers LDL-cholesterol in statin-treated patients without harmful effects over a period of 12 weeks. What a breakthrough. Why, in another five years we might know if it benefits patients, or kills them.
http://content.nejm.org/cgi/content/abstract/362/10/906
Lancet 13 Mar 2010 Vol 375
This issue is dominated by the question of blood pressure variability and stroke, and by the intellectual presence of Peter Rothwell, in both the papers (pp.895, 906) and in a long review on p.938. This is impressive, and a Good Thing. Rothwell is a neurologist and is most interested in what happens to link blood pressure with stroke - a sudden process. Not surprisingly, strokes are linked with labile visit-to-visit SBP, indicating a tendency to sudden surges. At the moment in clinical practice we throw these babies away as bathwater. We disregard both pulse pressure and variation, and relax the moment we can enter a BP of less than 150/90 on the patient record. This needs to change following these papers. The evidence is that the best drugs to reduce BP variability are calcium channel blockers and thiazide diuretic, whereas most other drug classes actually increase BP variability. Bendroflumethiazide may well go back in the Polypill, because we know that most people over 65 need a BP reducing agent and that BFZ reduces both stroke and heart failure - albeit at the expense of harmless induced hyperglycaemia which we are inclined to mislabel as diabetes.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60308-X/abstracthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60235-8/abstracthttp://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60309-1/abstract
Arch Intern Med 8 Mar 2010 Vol 170
433 The meticulous work of outcomes assessment in real life situations continues, and nobody does it better than Harlan Krumholz and his team at Yale. This week they turn their attention to differences in patient survival after myocardial infarction by hospital capability to perform percutaneous coronary intervention. In the USA, as here in the UK, there is a big debate about how best to regionalise services to ensure that as many people as possible can get timely PCI following MI. The real life situation proves to be far from simple: some regions might get better outcomes from centralisation, but others not.
http://archinte.ama-assn.org/cgi/content/abstract/170/5/433
Showing posts with label coronary angiography. Show all posts
Showing posts with label coronary angiography. Show all posts
Thursday, 18 March 2010
Wednesday, 10 February 2010
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
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
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