December 9th, 2013

Selections from Richard Lehman’s Literature Review: December 9th

CardioExchange is pleased to reprint this selection 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  5 Dec 2013  Vol 369

Targeted Temperature Management at 33°C vs. 36°C After Cardiac Arrest (pg. 2183): Respect: this trial collected nearly a thousand patients who survived out-of-hospital cardiac arrest and ended up in one of 36 intensive care units spread across Europe and Australia. They were then randomised to treatment involving hypothermia to 33 deg celsius—as recommended by current guidelines—or without hypothermia. This logistic feat proved worthwhile, because it shows that hypothermia achieves nothing. This futile procedure can be dropped at once. Cooling is not cool.

Bivalirudin Started During Emergency Transport for Primary PCI (pg. 2207): Although I try to report advances in the management of myocardial infarction for you every week, if I had a heart attack myself I would have only the faintest idea what my options really were and what their relative harms and merits might be. Perhaps as I was sucking on my aspirin tablet, I might ask the paramedic to leave the blood pressure cuff inflated for about five minutes to achieve a bit of ischaemic preconditioning. I might call for a tot of cardioprotective brandy: they say it goes well with diamorphine. Has anyone done a trial of oral alcohol for acute MI? I suppose I would let the ambulance take me to the nearest catheter lab for PCI, although more than an hour might elapse before I even reached the hospital door. What should I accept on the way there? The Medicines Company hope that I would say bivalirudin. In the EUROMAX trial that they funded, 2218 people with AMI were randomised to either receive bivalirudin on the way to a PCI centre, or else a “optional receipt of a glycoprotein IIb/IIIa inhibitor.” A rather odd study design, made even odder by a change in the composite primary end-point after the trial had started. So compared with optional receipt of a glycoprotein IIb/IIIa inhibitor, and using the post-commencement composite end-point of death or major bleeding not associated with coronary-artery bypass grafting (CABG), “Bivalirudin, started during transport for primary PCI, improved 30-day clinical outcomes with a reduction in major bleeding but with an increase in acute stent thrombosis.” Is that clear to everybody? Would you ask for bivalirudin in the ambulance?

Lancet   7 Dec 2013  Vol 382

Safety and Efficacy of Drug-Eluting Stents in Women (pg. 1879):  The Lancet is a very odd journal, in case you hadn’t noticed. Some weeks it contains pharma-funded phase 2 trials of astounding clinical irrelevance; occasionally it contains important papers heralding major breakthroughs, or reporting massive RCTs; then there are some issues entirely devoted to health in a particular part of the globe you are unlikely to visit; last week the journal was all about sex and the British, in case you are thinking of having sex in Britain; and this week the entire research section is taken up with this analysis the safety and efficacy of drug-eluting stents in women, based on patient-level results from 26 randomised trials; plus a paper on risk stratification at diagnosis for children with hypertrophic cardiomyopathy. We seem to have wandered into the pages of Circulation rather than The Lancet. Anyway, the message from the stents-for-women analysis is that drug-eluting stents are safer than bare metal stents, and that second-generation drug-eluters are better than first generation. This is very much what pharma would like you to believe, so I am inclined to disbelieve it. But then neither I nor you, dear reader, are in a position to re-interrogate the data and the methods of 26 major trials. We must believe what we read, and buy the latest products.

BMJ   7 Dec 2013  Vol 347

Target Cardiovascular Risk Rather than Cholesterol Concentration: For me, the best thing in this week’s BMJ is an editorial by Harlan Krumholz about the new cholesterol-lowering guidelines from the American College of Cardiology and the American Heart Association. Those who read this column regularly will realise that I am quite a fan of Harlan’s work, and in this case he can take some credit for a major change in policy by these organisations. For many years he has pointed out the fact that statins alone among LDL-cholesterol lowering drugs reduce cardiovascular risk, and that using them should depend on the level of risk, not the level of cholesterol. When he and Rod Hayward wrote an open letter to the guideline committee two years ago in Circulation: Cardiovascular Quality and Outcomes, there were dark mutterings about undermining public confidence in medical practice. But now the same people have looked at the evidence and come up with a guideline that embodies a model based on risk, and that acknowledges that cheap generic statins have a solid evidence base that other lipid-lowering drugs lack. Harlan generously acknowledges this change of heart. Nothing is more difficult for authority figures than to change their minds in public: look at the diabetes community, still wriggling around the issue of targets in type 2 diabetes. I think Harlan’s commentary is not only the best written, but also the most persuasive, of all the many that have appeared in the last two weeks. Several others have been excellent, including one by Ioannidis available free on the JAMA website.




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