July 15th, 2013
Selections from Richard Lehman’s Literature Review: July 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 July 2013 Vol 310
Prevalence and Extent of Obstructive CAD Among Patients Undergoing Elective Coronary Catheterization in New York State and Ontario (pg. 163): A clinical review in the NEJM a couple of months ago told us to change our whole conception about coronary atheroma: the really “critical” plaques may not be the ones that cause the obvious stenoses. On the contrary, the true villains are probably the deep soft fatty plaques that may not even disturb the lumen until they crack open and cause a thrombotic cascade. This thinking has yet to permeate the research literature, if it ever does: the “blocked” pipe analogy of CAD is so convenient for both patients and interventional cardiologists. And existing plaque is probably a good surrogate for hidden plaque, and should serve as a warning to use clot stabilising medications. I digress, led on by the fact that in New York State, nearly 70% of people subjected to coronary angiography have no obstructive atheroma, whereas in Ontario not far north, the figure is 55%.
Medical Management After Coronary Stent Implantation (pg. 189): I’m not a cardiologist, and I don’t get time to read all the specialist journals, but has there been any further work since COURAGE on stenting compared with various antithrombotic regimens for stable coronary disease? I’m led to wonder because there seem to be an awful lot of trials comparing agents after stenting—this review covers them—but not a lot about simply giving the drugs and omitting the stent. It seems to me that whenever a cardiologist does an angiogram on a person without unstable symptoms, all stents should be removed from the building, but maybe I’m missing something.
NEJM 11July 2013 Vol 369
CV Effects of Intensive Lifestyle Intervention in Type 2 Diabetes (pg. 145): What can we do about type 2 diabetes? At present we achieve most benefit by controlling blood pressure and prescribing statins, and a bit of good by keeping glycated Hb under 9%. But surely we would achieve the greatest reductions in cardiovascular events through an intensive lifestyle intervention to increase exercise and reduce weight? The Look AHEAD trial hoped to prove this within the pre-specified thirteen years, but instead it was abandoned for futility at 9.6 years. The patients in the intervention arm did well at keeping their weight down and having better levels of fitness; they even had lower sugar levels; but they did not score better on a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for angina. This is a truly disappointing result from a well-designed non-drug trial which worked hard to achieve its desired surrogate end-points, but failed to achieve the end-points that mattered. Everybody would like to see a positive result from a trial in diabetes; but so far only bariatric surgery seems to deliver any goods, and that’s a message not one of us really likes to hear.