October 22nd, 2012

Selections from Richard Lehman’s Literature Review: October 22nd

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  17 Oct 2012  Vol 308

Favorable Lipid-Level Trends in U.S. Adults (pg. 1545): “Between 1988 and 2010, favorable trends in lipid levels have occurred among adults in the United States.” That may seem pretty amazing, but there is a lot we don’t understand about these things. Remember that cardiovascular disease is also falling steeply, even as the population gets more obese. The authors of the NHaNES analysis speculate that the cause of the fall in total cholesterol and LDL-cholesterol may be linked with a fall in sugar consumption and smoking. Greater use of lipid-lowering drugs has contributed very little to the overall decline.

Lancet  20 Oct 2012  Vol 380

Angiotensin Receptor Neprilysin Inhibitor for Patients with HF and Preserved Systolic Ejection Fraction (pg. 1387): Here is a truly obscure phase 2 trial of a drug which doesn’t yet have a name in a group of patients hitherto largely ignored by the cardiology community, especially in the UK—people with heart failure and preserved systolic ejection fraction. The drug is classed as an angiotensin receptor neprilysin inhibitor (ARNI)—I won’t try and explain but you can think of it as an angiotensin receptor blocker with bells on. The comparator was an ordinary ARB (valsartan), and the end point was N-terminal proBNP at 12 weeks. So far, so bad: what is this trial doing in The Lancet, and why am I bothering to tell you about it? I don’t know the Lancet’s reason, but mine is that I want to go on about heart failure and BNP yet again. This hormone is an excellent marker for ventricular strain but it is very variable physiologically and not a reliable way to monitor treatment in individuals. So of course this trial is worthless in itself and needs to be followed by one that has hard end-points. BNP is raised equally in all patients with heart failure, whether or not they have reduced ejection fraction, and is an excellent predictor of death. It is high time that we used highly elevated BNP despite optimal treatment as an indicator that patients should receive palliative and supportive care. As for these new ARNI drugs and their place in the great scheme of things, you can learn more from the editorial by John Cleland and Andrew Clark, which usefully challenges the primacy of systolic ejection fraction as a measurement in heart failure.

Long-Term Safety of the Zotarolimus-Eluting and Sirolimus-Eluting Coronary Stents (pg. 1396): Blimey. I thought that the Stent Wars were over, and that all sensible earthlings long since clambered into their starships and returned to the home planet. Not so, apparently: far out there, sirolimus and zotarolimus are busy eluting in competition with another, and their light beams are now reaching Earth. It’s an exciting draw: there is no difference in stent thrombosis: but the plaintive cry of the Medtronic-funded investigators is that “Time analysis suggests a difference in definite or probable stent thrombosis between groups is emerging over time, and a longer follow-up is therefore needed given the clinical relevance of stent thrombosis.” What, will the Stent Wars stretch out to the crack of doom?

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