September 6th, 2012
Selections from Richard Lehman’s Literature Review: September 6th
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.
NEJM 30 Aug 2012 Vol 367
Aspirin Plus Clopidogrel in Patients with Recent Lacunar Stroke (pg. 817): Aspirin is an annoyingly good drug, which may have made Bayer’s fortune over a century ago but makes nobody much money now. Nonetheless, drug companies continue to seek for a marketable antiplatelet drug to replace or complement aspirin, and clopidogrel has been a very nice little earner during the period of its patent. This trial sought to establish whether combining clopidogrel with aspirin would reduce recurrent stroke after recent lacunar stroke. The aspirin dose was set high at 325mg, and adding clopidogrel to this made no difference to stroke recurrence but did cause more intracranial haemorrhage and was associated with higher mortality.
Lancet 1 Sep 2012 Vol 380
Risk of Coronary Events in Patients with CKD or Diabetes (pg. 807): In my last two weekly reviews, I’ve railed against the use of the expression chronic kidney disease without further explanation of what is actually meant. This paper adds a new twist to the crime: it uses a cut off eGFR of less than 60 in some places, and an eGFR of 45 in others. It refers to 3 grades of proteinuria, and finds that only the top level is predictive; but elsewhere the authors freely use the word “proteinuria,” without specifying its precise meaning or its relationship to eGFR. Most annoyingly of all, the authors talk about CKD in terms of how it compares with type 2 diabetes as a risk for myocardial infarction, usually without adjustment for age. As a result, this analysis of data from the Alberta Kidney Disease Network and the National Health and Nutrition Examination Survey (NHANES) 2003-06 manages to be exceedingly cumbrous while failing to convey any clear clinical message. It will no doubt be used by advocates of universal screening for CKD—ignoring the fact the mean age of the “at-risk” group here was 71, an age at which most people should have been taking statins for 20 years if they wish to reduce their odds of cardiovascular disease—irrespective of their kidney function, or indeed their blood sugar.
2 Responses to “Selections from Richard Lehman’s Literature Review: September 6th”
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“It will no doubt be used by advocates of universal screening for CKD—ignoring the fact the mean age of the “at-risk” group here was 71, an age at which most people should have been taking statins for 20 years if they wish to reduce their odds of cardiovascular disease—irrespective of their kidney function, or indeed their blood sugar.”
This is a questionable statement at best. What is the evidence that all individuals should start a statin at age 50, regardless of their risk? What about low risk individuals who have maximized healthy lifestyles including daily exercise, plant-based carbohydrate-restricted diets, have normal BP, fasting insulin, and lipid parameters, and don’t smoke. What is the net benefit of statin in such individuals when their lifestyle has already lowered their risk by 90%? (See Lyon Heart Study, Nurses Health Study and many others). Yes age is the maximal driver of risk but in low risk individuals who are willing to comply with lifestyle modification, there is no role for statins or other medications.
The case for statins for all at the age of 50 was made in an editorial by Shah Ebrahim and Juan P Casas in The Lancet a month ago, commenting on a meta-analysis of 27 RCTs which included statin treatment in low-risk individuals.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960367-5/abstract
You can argue about the age cut-off but not about the percentage risk reduction – which is obviously of least importance in individuals who are the lowest risk, such as those Dr Hackam describes. I would argue that everyone should have access to cheap, highly potent statins and make their own decision whether to take them, factoring in their personal risk score if they wish, and their health beliefs, preferences and willingness to alter their lifestyle. Some individuals may need to give up due to muscle symptoms, but for the majority these drugs fulfil the criteria of the American Founding Fathers, promoting life, liberty, and the pursuit of happiness.