November 26th, 2012

Selections from Richard Lehman’s Literature Review: November 26th

CardioExchange is pleased to reprint selections from Dr. Richard Lehman’s weekly journal review blog at Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

JAMA  21 Nov 2012  Vol 308

Fish Oil and Postoperative AF: OPERA is the quintessential Italian art-form: devised as a return to the classical past, it is a brilliant transitory display of music, costume, and painted stage sets; an escape to a heightened form of existence and emotion. Palpitations are to be found everywhere: in fact the aria Di tanti palpiti from Rossini’s Tancredi was a great nineteenth century favourite. Oily fish, on the other hand, play but a small part in the operatic repertoire, to the best of my knowledge. Were I sufficiently versed in the full range of Italian musical drama, I might be able to cite the odd eel or mackerel. Perhaps there may be a herring in Lucia di Lammermoor. The climax of Maria Stuarda probably involves a salmon. Alas, I am an infrequent visitor of the opera house, and no sound guide on this important topic: all I am trying to do is to relieve the tedium of reporting on an Italian trial of fish oil in post-operative atrial fibrillation, called OPERA. “In this large multinational trial among patients undergoing cardiac surgery, perioperative supplementation with n-3-PUFAs, compared with placebo, did not reduce the risk of postoperative AF.”

NEJM  22 Nov 2012  Vol 367

Low-Dose Aspirin for Preventing Recurrent VTE (pg. 1979): When Felix Hoffmann, working for the Bayer company in 1897, acetylated salicylic acid and produced aspirin, he produced a drug that we are still learning new uses for. The ASPIRE trial looked at the effect of low dose aspirin (100mg) on events following the discontinuation of anticoagulation for a first episode of venous thromboembolism. The enteric-coated aspirin was provided free by Bayer (they still make plenty); the study was publicly funded in Australia and New Zealand. They had recruitment problems despite using 56 sites in 5 countries, but they did manage to conduct a double-blinded trial on 822 patients over 4 years. As far as thromboembolic event prevention went, the benefit did not reach significance—though taken with the results of the WARFASA trial, there is a definite signal for protection. But if you add in stroke, myocardial infarction and cardiovascular death, there was a significant reduction of 34%. It looks as if people who have had any episode of VTE might be well advised to take 100mg of Bayer enteric-coated aspirin daily: with this preparation, there was no increase in bleeding events.

Endovascular vs. Open Repair of Abdominal Aortic Aneurysm (pg. 1988): When you are trying to share decision making with patients, you need reliable data from a representative population, and you need it presented in a form that the patient can understand. Imagine that you are a man who has to decide on surgery for aortic abdominal aneurysm: you have a time-bomb ticking in your belly; it may never go off; if it does you may well die. Better have it repaired, then, but that too carries a small but significant risk of death, amounting to 3% if you have an open operation (in this study) or 0.5% if you have endovascular repair. In the long term, though, the mortality figures are equal, as this 881-strong trial shows. There is also a fine balance between major harms and complications. Here is a perfect example of a major preference-sensitive decision which requires an option grid. Don’t know what an option grid is? Look them up here.

BMJ  24 Nov 2012  Vol 345

Novel Oral Anticoagulants for Treatment of Acute VTE: Call me old-fashioned, but I think that if you want to compare two interventions, you have to do a randomized controlled trial of one versus the other. You can do indirect comparisons but only to generate hypotheses or give interim guidance to clinicians. It would be nice to believe this direct and indirect meta-analysis which claims that all novel oral anticoagulants are equivalent to warfarin in the management of venous thromboembolism, but I doubt whether it is as simple as that.

Resistant hypertension is the subject of this week’s BMJ Clinical Review, and the evenly high quality of the series continues. It really is worth taking some trouble over these patients. Poor compliance is often cited as a cause, but a person who is willing to keep coming back for BP checks is not likely to be non-compliant with therapy in my experience. There is more likely to be an underlying reason such as hyperaldosteronism. Forget QOF and look carefully at these high-risk people, and let this article be your guide.

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