ARTICLE ABSTRACTS FROM WATCH

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