April 10th, 2012
Selections from Richard Lehman’s Literature Review: Week of April 10th
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 April 10th
NEJM 5 Apr 2012 Vol 366
Rivoroxaban (pg. 1287): The successful EINSTEIN-PE trial of rivoroxaban has been talked about for a while, and you don’t have to be Einstein to work out that this is very good news for Bayer HealthCare and Janssen Pharmaceuticals, who co-funded the trial. It was an open-label trial, pitting the new oral fixed-dose factor Xa inhibitor against an adjusted-dose vitamin K antagonist (in the States, they use dicoumarol as well as warfarin) for 3, 6 or 12 months after symptomatic pulmonary embolism. As far as I can tell (and you know I am far from infallible) the stuff did what the manufacturers put on the can: rivaroxaban was as good at preventing recurrences, and less likely to cause major bleeds than a coumarol/INR regime.
Cancer Diagnosis and Risk for Suicide/Cardiovascular Death (pg. 1310): Here’s a really thought-provoking study from Sweden showing that in the week after receiving a cancer diagnosis, the relative risk of suicide goes up by 12.6 and the RR for cardiovascular death by 5.6. Taken over the first year, the risk ratios are slightly over 3 for both. The immediate cardiovascular effects of a shocking diagnosis could hardly be more dramatically demonstrated, while the continuing physical effect could be partly explained by prothrombotic and inflammatory effects from the cancer itself. But the suicide figures once again raise the question of what is an “appropriate” response to a cancer diagnosis. Palliative care specialists, at least in the UK, share a religious predisposition to expect all cancer patients, at whatever stage, to bear their sufferings to the end, encouraged by promises (which may be undeliverable) of complete relief. To me personally, this interpretation of the will of God seems neither rational or generous, nor even always honest. The original Zarathustrian religion of good thoughts, good words and good deeds seems to me a better guide: it acknowledges that God (or good, or whatever you want to call it) can only act through man in the physical world. Suicide in the first week of diagnosis is likely to be an immediate distress reaction, almost certain to cause a lot of distress in others: it is not irrational, but is usually best averted if possible. But well-planned suicide in the face of impending suffering and death does not seem to me either irrational or ignoble, provided it is done with full consideration to others.
Lancet 7 Apr 2012 Vol 379
Computer Reminders vs. Pharmacist Outreach (pg. 1310): This cluster-randomized trial from British general practice compared computer-generated reminders about medication dangers with something they grippingly called PINCER – “a pharmacist-led information technology intervention, composed of feedback, educational outreach, and dedicated support”. You can choose which you hate most – this description or the acronym. The end-points were: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. Fair enough, I suppose (though I suspect some surprises when someone eventually looks at the end-points in “asthma” patients given very low-dose β blockers versus those given β agonists): and of course the PINCERed practices did better. So what should you commissioning guys invest in? More paid-for interference – sorry, I mean outreach and dedicated support – by community pharmacists, or punchier, clearer computer reminders?