April 16th, 2013
Selections from Richard Lehman’s Literature Review: April 16th
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 11 Apr 2013 Vol 368
Fibrinolysis or Primary PCI in STEMI (pg. 1379): When it became clear about ten years ago that immediate percutaneous coronary intervention was the treatment of choice for myocardial infarction, I advised readers to have their MI on a Thursday morning in a large city where there was a sporting chance that there might be a fully staffed cardiac catheter suite ready to receive them. The treatment of first choice remains very challenging to provide: so how much worse is the treatment of second choice—immediate (prehospital) fibrinolysis, followed by PCI at relative leisure (6-24hrs later)? The answer is that the two strategies are equally good when judged by a composite end-point of death, shock, congestive heart failure, or reinfarction up to 30 days. The only drawback was a greater incidence of cerebral haemorrhage in the primary thrombolysis group, due to their cocktail of tenecteplase, clopidogrel, and enoxaparin. Dose adjustment helped to reduce this in the later stages of the trial. Overall, this is very good news for those working out how best to provide safe MI services around the world.
BMJ 13 Apr 2013 Vol 346
Effect of Lower Sodium Intake on Health: The BMJ has published a systematic review of the effect of lower salt intake on health. The conclusion dutifully states, “Lower sodium intake is also associated with a reduced risk of stroke and fatal coronary heart disease in adults. The totality of evidence suggests that most people will likely benefit from reducing sodium intake.” In Thatcher week, should we reply “Rejoice!” or “No, no, no!”? I suggest the latter. The summary in the printed BMJ says it all: “Low and very low quality evidence suggest that lower sodium intake is associated with reduced risk of stroke, fatal stroke, and fatal coronary disease in adults.” Again, there is a good response from Copenhagen. “The conclusion of the analysis is not justified by the data, but that is not the issue. The interesting question is why BMJ use 20 pages on the publication. The answer may be that the science of salt is not scientific, but political.”
Effect of Increased Potassium Intake on CV Risk Factors and Disease: But potassium is probably good. I’m not saying the evidence is perfect—it never can be—but this systematic review concludes “High quality evidence shows that increased potassium intake reduces blood pressure in people with hypertension and has no adverse effect on blood lipid concentrations, catecholamine concentrations, or renal function in adults. Higher potassium intake was associated with a 24% lower risk of stroke (moderate quality evidence).” Eat bananas and tomatoes. Drink fruit juice. Accentuate the positive.