March 17th, 2014
Selections from Richard Lehman’s Literature Review: March 17th
Richard Lehman, BM, BCh, MRCGP
CardioExchange is pleased to reprint this selection 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.
Lancet 15 Mar 2014 Vol 383
Comparison of the Efficacy and Safety of New Oral Anticoagulants with Warfarin in Patients with AF (pg. 955): “And God saw every thing that he had made, and, behold, it was very good.” Gen 1.31. This meta analysis of new oral anticoagulants for atrial fibrillation breathes a similar air of contentment. They are, quite simply, better than warfarin, especially when INR control is suboptimal. In an overall comparison with warfarin, they decrease all-cause mortality by about 10%, and reduce stroke and other embolic events by about 19%. What’s not to like? Well, a bit more gastrointestinal bleeding and a lot more cost. So if you have AF and feel strongly, you should follow the advice of the director of NICE and march along to your GP and demand some dabigatran. Or apixaban. Or rivaroxaban. Or wait a bit, until edoxaban has been approved. Why should you worry about cost to the NHS? When did anyone ever ask you about how much the nation should spend on health, or fulfil an electoral promise about the NHS?
Mortality from Ruptured Abdominal Aortic Aneurysms (pg. 963): It’s blood-in-the-boots time again folks. In the UK, more than 90% of ruptured abdominal aortic aneurysms are repaired by open surgery, whereas in the USA, the figure is 79%. Over there, they offer surgery to a lot more people too: 80% of those with ruptured AAA as opposed to 58% here. Yet their in-hospital mortality is somewhat better than ours, at 53 versus 66%. So we must learn lessons from America, but it isn’t quite clear what these are. The main one seems to be to rush off people with rAAA to high volume centres.
Metabolic Mediators of the Effects of BMI, Overweight, and Obesity on CHD and Stroke (pg. 970): As an aging man who likes food and doesn’t get much time away from a desk, I puzzle about the importance of overweight. It seems to me that the main problem is the tightness of one’s clothes. This is somewhat confirmed by this Lancet analysis, which concludes that “Interventions that reduce high blood pressure, cholesterol, and glucose might address about half of excess risk of coronary heart disease and three-quarters of excess risk of stroke associated with high BMI. Maintenance of optimum bodyweight is needed for the full benefits.” The last has to be true. Taking losartan and a statin has made no difference whatever to the tightness of my clothes.
The Framingham Heart Study and the Epidemiology of Cardiovascular Disease (pg. 999): In a few weeks’ time, all who can should visit Framingham, Mass. The Woodland Garden there will be full of the most wonderful erythroniums, trilliums, and sanguinarias. Others may wish to make the pilgrimage because it is 65 years since the first subjects were recruited to the Framingham Heart Study, marking the beginning of a new era in epidemiology. Here is a fascinating history of the project, which was stimulated in part by F.D. Roosevelt’s death from galloping hypertension. It’s a wonderful reminder of how much good work could be done by means of messages written on rickety typewriters, simple paper charts, and card indexes. No internet for the first 40 years.
BMJ 15 Mar 2014 Vol 348
Exclusion of DVT Using the Wells Rule in Clinically Important Subgroups: When faced with a possible deep vein thrombosis, I try to apply the Wells rules and do a d-dimer test, but I’m constantly frustrated at how often they simply don’t apply to the clinical situation. This individual patient data meta-analysis, whose authors include the great Professor Wells himself, concludes that “Combined with a negative D-dimer test result (both quantitative and qualitative), deep vein thrombosis can be excluded in patients with an unlikely score on the Wells rule. This finding is true for both sexes, as well as for patients presenting in primary and hospital care. In patients with cancer, the combination is neither safe nor efficient. For patients with suspected recurrent disease, one extra point should be added to the rule to enable a safe exclusion.” Add to this pregnant women and elderly people with fragility bruises, and you find yourself giving a lot of LMW heparin until you can get a scan, just in case.