January 30th, 2012

Selections from Richard Lehman’s Weekly Review: Week of January 30th

CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at BMJ.com. Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

Week of January 30th

NEJM  26 Jan 2012  Vol 366

321  Here is a classic paper which describes the lifetime risks of cardiovascular disease: though the very fact of its being a printed article places absurd limits on its usefulness. A meta-analysis like this, covering more than a quarter of a million people from the age of 45 till death, needs a whole website with full databases and several banks of Powerpoint slides. Traditional publishing is rubbish when it comes to a topic like this: and you don’t even get open access to these printed titbits. Suffice to say that wherever you live and whatever your ancestry, your CV risk is a simple function of four factors: blood pressure, smoking, cholesterol, and diabetes. These are all continuous variables, and we are looking at 18 cohorts studies involving 257,384 individuals. And here is an 8-page article: what a way to carry on in the year 2012!

Lancet  28 Jan 2012  Vol 379

322    I’ve already commented on this meta-analysis by Carl Heneghan et al of individual patient data relating to self-monitoring of anticoagulation, which has major implications for clinical practice. Come on, primary care academia: there is more low-hanging fruit like this if only you would get on and pick it.

Arch Intern Med  23 Jan 2012  Vol 172

98     Ever since immediate percutaneous coronary intervention was shown to be superior to thrombolysis for high-risk ST-elevation myocardial infarction, health systems have been pouring huge resources into providing 24-hour immediate PCI facilities, but with inevitably mixed success. Outcomes researchers in the USA have come up with some pretty dire statistics for time to transfer from hospitals without PCI capacity to hospitals with, and in this editorial Rita Redberg grasps the nettle and urges a more realistic approach: “For low and intermediate risk patients, there is no mortality advantage to primary PCI (pPCI) over thrombolytic therapy. Even for high-risk patients with STEMI, the mortality benefit of pPCI is frequently lost due to routine delays of 1-3 hours by transfer. It is time to reconsider transferring patients with STEMI for pPCI. Timely reperfusion by thrombolytics, not late pPCI via transfer, will save lives.” Discuss.

101    Popular myth tells us that exercise combats depression by producing endorphins – or is it serotonin? – and for all I know popular myth may be right. There’s no doubt that exercise has other benefits too, so it’s nice to know from this systematic review that the antidepressant effect of exercise in chronic illness is supported by evidence from a large number of trials in a large range of conditions.

144    I would like to claim that the population benefits of taking statins are not outweighed by any potential for irreversible harm, and that now they are so cheap there is no reason why anyone should be advised against taking a statin if they wish to reduce their cardiovascular risk. There is no threshold effect, after all. But now there is a nagging worry that statins may induce diabetes, confirmed here by data from the Women’s Health Initiative, which included over 150,000 postmenopausal women without diabetes at baseline. This needs a lot more investigation: there is a lot of scope in such studies for residual confounders, including confounding by indication; and we need to know more about the potential reversibility of statin-induced hyperglycaemia.

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