SNIPPETS FROM JOURNAL WATCH

NEJM 15 July 2010 Vol 363
245 If anything can cause a company's profits to BLOOM, it's a new obesity drug. The BLOOM (Behavioural Modification and Lorcaserin for Overweight and Obesity Management) trial was funded by Arena Pharmaceuticals, who will be hoping for vast returns on the latest drug to target the serotonin receptor. Those with supernaturally good memories and profound knowledge of clinical pharmacology (OK, you can put your hand down, Jeff Aronson) will remember that there are actually three such receptors and that previous anti-obesity drugs such as fenfluramine and dexfenfluramine targeted them non-specifically. They worked fairly well for appetite suppression but were withdrawn because they could cause valvular heart defects and pulmonary hypertension. This is because cells around the heart valves and in the pulmonary vasculature contain 5HT2B receptors whereas the receptor you need to hit for appetite suppression is 5HT2C. Lorcaserin is powerfully specific for this receptor and Arena went out of their way to check their trial subjects regularly with echocardiograms which prove that it doesn't cause heart valve problems in the first two years. Whereas it certainly does help people lose weight and will be advertised as blooming wonderful if and when it gets it licence. http://content.nejm.org/cgi/content/abstract/363/3/245

266 In reviews of acute pulmonary embolism I look for two things: mention of it as a common cause of exacerbations in heart failure and COPD, and guidance about which patients need long-term anticoagulation. This article by two Italian authors doesn't fully satisfy either criterion. There's little mention of HF or COPD and although they say that "extended treatment requires a reassessment of the patient's risk-benefit ratio at periodic intervals" they fail to tell us how to calculate these risks and benefits.
http://content.nejm.org/cgi/content/extract/363/3/266

Lancet 17 July 2010 Vol 376
163 Droves of healthy people come to see doctors all year round to have blood pressure checks. If it's off target, their GP sees them every few weeks to make adjustments. Neither the timing, the place nor the health professional involved reflects any real logic. This ground-breaking study (TASMINH2) addresses these realities by passing management to the patient whose blood pressure is monitored at home with a reliable automatic device linked by an automated modem to the GP practice. If it remains high, the patient is given advice and if necessary additional drug treatment to reduce it. The group randomised to this intervention showed usefully better control of systolic BP at the end of a year. If this technology became widespread, we would save many GP appointments and improve control in most of our hypertensive patients.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60964-6/abstract

Lancet 10 July 2010 Vol 376
112 Exercise will also help you avoid a stroke; alcohol alas will not. Most of the other risk factors for stroke identified by the INTERSTROKE study are the ones you might expect, and the ten main ones account for nearly 90% of the risk. The oddest feature is the role of body mass index: when corrected for other factors, a high BMI actually seems protective, whereas a high waist-to-hip ratio is a substantial risk factor.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60834-3/abstract

NEJM 1 Jul 2010 Vol 363
36 Implantable cardioverter-defibrillators often go wrong due to lead failure, and they can lead to shockingly bad ends in heart failure. This trial assesses a new type of ICD which does not rely on venous access but is entirely subcutaneous, delivering shocks to the thorax close to the heart. Its success depended a lot on accurate positioning, and over the ten months of the trial it worked well and appropriately, though it's too soon of course to say anything about long-term reliability, let alone long-term mortality benefit.
http://content.nejm.org/cgi/content/abstract/363/1/36

1037 The well-conceived new Archives series called LESS IS MORE here lives up to its radical credentials: we are giving diabetic patients too many drugs for cardiovascular protection. Again, this flies in the face of what we have been taught over the last few years. It also seems to fly in the face of the calculation done by these authors that treating to targets for LDL-cholesterol and blood pressure results in gains of 1.5 and I.35 quality-adjusted years respectively. But they demonstrate that these overall gains are largely accounted for by the treatment of a small number of very high-risk individuals, and that the more drugs you put in, the more you are likely to achieve minimal benefit or actual harm. A key paper in the continuing debate about targets in type 2 diabetes.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1037

Arch Intern Med 28 Jun 2010 Vol 170
1024 If in doubt prescribe statins. Among patients with known cardiovascular disease, it is very hard to find any benefit once heart failure has set in. But prescribing statins to high-risk patients for primary prevention may be futile, according to this literature-based meta-analysis. It is a very hard paper to follow, however, with a fairly heterogeneous mix of studies which are not adequately characterised or analysed in these six pages: to do that would require twice the length, or ideally an entire database, which could then be analysed on an individual patient basis...
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1024

1032 The JUPITER trial of rosuvastatin was stopped early and has been a source of controversy ever since. The acronym stands for Justification for the Use of Statins in Primary Prevention, but when JUPITER's data are fed into a meta-analysis like the one we've just seen, there is no such Justification. In fact the data of this trial are internally contradictory in a way that strongly suggests manipulation, according to this critical reappraisal, which suggests that Jove's ire should be directed at the role of commercial sponsors.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1032

1037 The well-conceived new Archives series called LESS IS MORE here lives up to its radical credentials: we are giving diabetic patients too many drugs for cardiovascular protection. Again, this flies in the face of what we have been taught over the last few years. It also seems to fly in the face of the calculation done by these authors that treating to targets for LDL-cholesterol and blood pressure results in gains of 1.5 and I.35 quality-adjusted years respectively. But they demonstrate that these overall gains are largely accounted for by the treatment of a small number of very high-risk individuals, and that the more drugs you put in, the more you are likely to achieve minimal benefit or actual harm. A key paper in the continuing debate about targets in type 2 diabetes.
http://archinte.ama-assn.org/cgi/content/abstract/170/12/1037

National Library for Public Health News

Cardiovascular disease
Effect of high-carbohydrate or high-cis-monounsaturated fat diets on blood pressure: a meta-analysis of intervention trialsCentre for Reviews and Dissemination
Health economic evaluation of controlled and maintained physical exercise in the prevention of cardiovascular and other prosperity diseasesCentre for Reviews and Dissemination
Health Survey for England 2006 : CVD and risk factors adults, obesity and risk factors childrenThe Information Centre
Importance of salt in determining blood pressure in children: meta-analysis of controlled trialsCentre for Reviews and Dissemination
Long-term effects of weight-reducing interventions in hypertensive patients: systematic review and meta-analysisCentre for Reviews and Dissemination
Statins for the primary prevention of cardiovascular events in older adults: a review of the evidenceCentre for Reviews and Dissemination

Facts about Fat and Heart Fitness

Being fat is not something to be ashamed of, but it is something to be scared of, because of the proven link between obesity and heart disease. The United Kingdom is getting significantly heavier – more than 66 percent of adults are overweight or obese, and over the past ten years, the number of obese six-year-olds has doubled while the number of obese 15-year-olds has tripled. And that’s not the end of the bad news – 33 percent of adults, 20 percent of boys and 33 percent of girls are expected to be obese by the year 2020. These statistics reflect on our current lifestyles, and are definitely not a good sign for the nation’s heart health, what with the rising incidence of heart disease being connected to obesity, smoking and diabetes, all interlinked conditions.

In the meantime, a new study conducted by doctors from Germany and Switzerland claims that fat people are likely to live longer after a heart attack. They based their study on a group of 1,676 patients who had unstable angina or had suffered a heart attack between 1996 and 1999. The European Heart Journal reports that of the group, 9.9 percent of those in the normal weight category, 7.7 percent in the overweight category, and 3.6 percent in the obese category, died. But not a single person categorized as extremely obese died.

The reason for this miraculous survival? Well, according to the team of doctors, the fatter people were more likely to respond to the drugs prescribed to control cholesterol and blood pressure. Besides, they had a higher level of cannabinoids, cannabis-like compounds, in the brain, which help in the dilation of blood vessels and reduction of blood platelet counts, both of which are protect the heart.

So is this a faint ray of hope at the end of the obesity tunnel? Does this mean that fat people are not at risk for heart attacks any more? No, not at all – in fact, the lead doctor of the study cautioned overweight people against taking this report literally and putting off losing weight, because, all said and done, it is true that being obese decreases your life span by 9 years. And if your heart attack kills you as it most likely will, there’s no point in rejoicing that you’re fat enough to survive after the attack.

So get moving today, start working out to shed those excess pounds which could very well turn out to be your death knell.

In the UK, two thirds of adults are now overweight or obese. In the past ten years obesity has doubled in six-year-olds and trebled among 15-year-olds
Heavy matters
— A third of adults, a fifth of boys and a third of girls will be obese by 2020
— Obesity reduces life expectancy by an average of nine years
— Obesity doesn’t happen overnight: it takes about 3,500 excess calories to gain only 1lb (0.5kg)

By-line:
This article is contributed by Sarah Scrafford, who regularly writes on the topic of Online EKG Programs (http://www.ekgclasses.org). She invites your questions, comments and freelancing job inquiries at her email address: sarah.scrafford25@gmail.com.



Editor's note - this article was contributed with no evidence to base the facts given