May 28th, 2013

Selections from Richard Lehman’s Literature Review: May 28th

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.

NEJM  23 May 2013  Vol 368

Mechanisms of Acute Coronary Syndromes and Their Implications for Therapy (pg. 2004): The “blocked pipes” metaphor for coronary heart disease is so embedded in our thinking that it’s quite a challenge to persuade people—even doctors—to realise that the most dangerous places in the coronary arteries are usually not the places which look narrowest on angiograms. On the contrary, the most likely places for acute ulceration and clot formation are the soft fatty uncalcified lesions that may not even cause much apparent stenosis. If only we had better methods for identifying them. You can read all about this—and much else—in a really helpful single-author update on mechanisms of acute coronary syndromes, which is well worth seeking out if you are not a subscriber.

BMJ  25 May 2013  Vol 346

The Gap in Life Expectancy from Preventable Physical Illness, Including CVD, in Psychiatric Patients: This is the most shocking and shaming medical paper I’ve read for a long time: a survey of the gap in life expectancy for preventable physical illness in psychiatric patients. It comes from Western Australia, which presumably enjoys the same standards of psychiatric care as the rest of the rich world. “When using active prevalence of disorder (contact with services in previous five years), the life expectancy gap increased from 13.5 to 15.9 years for males and from 10.4 to 12.0 years for females between 1985 and 2005. Additionally, 77.7% of excess deaths were attributed to physical health conditions, including cardiovascular disease (29.9%) and cancer (13.5%). Suicide was the cause of 13.9% of excess deaths.” This is a scandal which needs urgent further investigation: are we becoming indifferent to physical illness and early death in the mentally ill? And are the newer drugs like olanzapine and quetiapine that we hand out so liberally actually contributing to an epidemic of cardiovascular disease in these patients?

Ann Intern Med  21 May 2013  Vol 158

Comparative Effectiveness of Multivessel CABG and Multivessel PCI (pg. 727): If you have stable coronary artery disease, your choices lie between optimal medical therapy, percutaneous coronary intervention (which generally means drug-eluting stents these days) or coronary artery bypass surgery. As a certain number of cardiologists read these reviews, I will avoid entering this minefield and simply give you the conclusions of this study of 105 156 propensity score–matched Medicare patients aged 66 and over who were followed up between 1992 and 2008. “Patients with diabetes, heart failure, peripheral arterial disease, or tobacco use had the largest predicted differences in survival after CABG, whereas those with none of these factors had slightly better survival after PCI.”

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