October 15th, 2012
Selections from Richard Lehman’s Literature Review: October 15th
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 10 Oct 2012 Vol 308
PCI Use in States with Public Reporting of Outcomes (pg. 1460): The first appeal for hospitals to disclose their outcome figures was made, believe it or not, in 1732, by Dr Francis Clifton of London. His canny eighteenth century colleagues shook their wigs, took a good pinch of snuff, and retorted that (a) individuals and institutions would try to cook their figures, and (b) this would act as a disincentive to accept the sickest patients or do risky procedures, even if they were potentially life-saving. Little has changed in nearly 300 years. This study examines percutaneous intervention rates and outcomes in US hospitals. “Among Medicare beneficiaries with acute MI, the use of PCI was lower for patients treated in 3 states with public reporting of PCI outcomes compared with patients treated in 7 regional control states without public reporting. However, there was no difference in overall acute MI mortality between states with and without public reporting.” This actually raises some pretty deep issues. But since most of my readers are not interested in cardiovascular outcomes research with special reference to the USA, I will move on. Those who are need to pore over this paper and also read the editorial.
Proneurotensin Related to CVD, Diabetes, Breast Cancer, and Mortality (pg. 1469): Another week, another prognostic marker for everything and nothing. “Exclusively in women, proneurotensin was related to incident diabetes (74 events; HR, 1.41; 95% CI, 1.12-1.77; P = .003), cardiovascular disease (224 events; HR, 1.33; 95% CI, 1.17-1.51; P < .001), breast cancer (123 events; HR, 1.44; 95% CI, 1.21-1.71; P < .001), total mortality (285 events; HR, 1.13; 95% CI, 1.01-1.27; P = .03), and cardiovascular mortality (75 events; HR, 1.50; 95% CI, 1.20-1.87; P < .001).” Measure enough weird chemicals in your cohort study, crunch the numbers, and hey presto! You have a paper in JAMA.
Lancet 13 Oct 2012 Vol 380
Vorapaxar for Secondary Prevention of Thrombotic Events for Patients with Previous MI (pg. 1317): Another Lancet issue with thin pickings for the jobbing clinician. Had you ever heard of vorapaxar? Maybe. Or of the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events (TRA 2°P)-TIMI 50 trial? Probably, if you are a cardiologist; otherwise, probably not. It was a vast 1,000-centre trial run by Merck to see it their new platelet inhibitor could win a place in the market of secondary prevention in patients with atherothrombosis. To this end, they chose a composite end-point of cardiovascular death, myocardial infarction, or stroke, and recruited nearly 27,000 subjects. They also pre-specified at least 7 subgroups, the largest being those with a myocardial infarction in the previous year—17,779 of the participants. In this group, vorapaxar does prove to have a protective benefit that outweighs the additional risk of bleeding. But the overall trial was stopped for harm, and cash-strapped health systems are unlikely to find the effect size sufficient to rush in and pay for the stuff to be given to every post-MI patient, especially when the field is already so crowded and hard to make sense of. For a valiant mapping attempt, see the editorial.
Arch Int Med 8 Oct 2012 Vol 172
Atenolol vs. Metoprolol for Hypertension: We often used to begin treating our hypertensive patients with ß-adrenergic blocking drugs, until long-term studies showed that atenolol actually didn’t seem to do any good and might even cause an increase in cardiovascular events. But can we say the same of metoprolol? Probably, and the way we can do it is by a simple retrospective database study—like this one, which shows no difference in a head on comparison of atenolol or metoprolol for uncomplicated hypertension. Even better, you could examine the issue prospectively by a very simple instant randomised allocation trial in UK primary care: except that nobody would opt to use beta-blockers for hypertension any more.