August 8th, 2012
Selections from Richard Lehman’s Literature Review: August 8th
Richard Lehman, BM, BCh, MRCGP
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.
JAMA 1 Aug 2012 Vol 308
Heart Failure and Depression (pg. 465): Living with heart failure is a miserable business, and about 40% of patients with this label are clinically depressed. This is due to a complex mix of factors: the biochemical “feel-bad” factors alone are too complex to list here, and they come from every system in the body, not just the left ventricle. Small wonder that depression in heart failure is associated with physical deconditioning and increased mortality. This study recruited 2322 subjects with systolic heart failure and depression from the USA, Canada and France and randomised them to an exercise programme or guideline-based care. At a median follow-up of 30 months, two-thirds of both groups were dead – these people really did have failing hearts. Survivors from the exercise group had slightly lower depression scores. The authors admit that this may be of little importance in the greater scheme of things. I would suggest that this study is one more illustration of the fact that people with heart failure and depression are in the final trajectory of their lives, and badly need the supportive and palliative care that so few of them can currently access.
Endoscopic vs. Open Vein-Graft Harvesting in Patients Undergoing CABG (pg. 475): The heyday of coronary artery bypass grafting is over, but I don’t see any end to the bickering over detail: off-pump or on-pump, arteries or veins, or if veins, harvested by endoscope or through a long incision. This careful registry search shows that on the last point, honours appear to be equal, in terms of mortality and revascularization, and using the endoscope leads to fewer immediate wound complications at the harvesting site.
Lancet 4 Aug 2012 Vol 380
Linagliptin vs. Glimepiride in Patients with Type-2 Diabetes (pg. 475): Like everybody else, I would really welcome the arrival of lots of new drugs to treat type 2 diabetes. I’m easily carried away by the optimism that surrounds the introduction of each new drug class, such as the gliptins or dipeptidyl peptidase-4 inhibitors. For all we know, these blood sugar lowering agents may be a real advance on the sulfonylureas we currently tend to use as second-line treatment. This trial comparing linagliptin with glimepiride shows that it lowers glucose by about the same amount, and with less risk of hypoglycaemia. But what of its long-term safety? And what effect does it have on the vascular events which are the main reason for treating diabetes? This trial was not designed to tell us about these, and we will simply have to wait for longer and bigger trials. In the meantime, each time you use a drug in this class, you are carrying out an experiment, and you have an ethical responsibility to tell your patient that you don’t know whether your treatment is going to be either safe or beneficial.
BMJ 4 Aug 2012 Vol 345
Weight Gain with Smoking Cessation: One of the biggest perceived barriers to smoking cessation is the fact that most people gain weight after quitting. This meta-analysis offers no comfort at all: it shows that the mean weight gain is 4-5kg and most of it happens within 3 months. Most people find it difficult enough to overcome nicotine addiction and the thought of gaining 10lb in a few weeks is hardly encouraging. It would be useful now if somebody could do a further meta-analysis to see if particular smoking cessation treatments can prevent some of this weight gain.
ACE Inhibitors and Pneumonia Risk: Inhibitors of angiotensin converting enzyme are also inhibitors of bradykin breakdown, so there is no such thing as an ACE inhibitor that does not increase coughing, especially during episodes of respiratory infection. Many people give up taking ACE inhibitors for this reason, but those who persevere are rewarded by a reduction in pneumonia, as demonstrated in this Portuguese systematic review. This effect is largest in observational studies carried out in Asia, and it is not seen with angiotensin receptor blockers, which have no effect on bradykinin breakdown.
Speech Therapy After Stroke: Speech therapy following stroke has no effect on speech recovery. The clear result of this Manchester trial will come as a blow not just to speech therapists but to many stroke sufferers and their families. Speech therapy is really supportive therapy, a token that society cares and is trying its best. The evidence here shows that you could take it away with no effect on speech, but that would leave people feeling that nobody was doing anything. And we disparage this kind of “futile” care at our peril: a lot of what we do as doctors falls in the same category. The difficult trick is to preserve this ability while remaining honest with ourselves and our patients.
“And we disparage this kind of “futile” care at our peril: a lot of what we do as doctors falls in the same category. ” I totally agree with this statement. Every day we are performing futile care, procedures, not for fiduciary gain or out of malicious conflict of interest but as doctors we are programed simply to help or to do everything. For example it is easier to open an occluded artery post myocardial infarction then to explain to the patient, family and the referring physician that an occluded artery few days post MI will make no difference in the overall prognosis. I hate to say it but only outside controls can prevent physicians from delivering futile care.
I wouldn’t compare speech therapy with opening occluded coronary arteries.