April 14th, 2014
Selections from Richard Lehman’s Literature Review: April 14th
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.
NEJM 10 Apr 2014 Vol 370
Spironolactone for Heart Failure with Preserved Ejection Fraction (pg. 1382): Human beings are programmed to die. One very common mode of dying is called heart failure. About half of people dying from heart failure do not show any diminution in the percentage of their left ventricular volume that they expel during systole, and in the clumsy jargon of the present, they are said to have HFPEF, heart failure with preserved ejection fraction. This is often referred to as “diastolic” HF, but in reality the mechanisms behind it are not confined to diastolic filling patterns but are far more complex. Let’s leave it at that, and consider what you might want to happen if you had a stiff, failing old heart. My main wishes would be to be looked after compassionately, not to be a burden on my loved ones, to get symptomatic relief for my breathlessness, and to avoid having to go into hospital. Knowing that this was how I would probably die, I might reach the point where I wanted it to happen quickly. These may not be everybody’s aims: some might wish to hang on to life as long as possible, but this seems a very odd assumption to turn into a primary outcome for trials in heart failure, as it invariably is. The median age in the TOPCAT trial was 68, at least a decade younger than most patients with HFPEF. This was essentially a rerun of the trials of spironolactone in systolic heart failure done over the last 20 years. In heart failure with an ejection fraction of 45% or more, spironolactone did not reduce the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. My plea would be for researchers to start looking at other end-points, centred on the quality of dying.
Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism (pg. 1402): Ever had a pulmonary embolus? Don’t answer no, because in truth you have no idea. Thousands of tiny clots could have passed through your pulmonary circulation without you being any the wiser. The lung is a sieve, and pulmonary embolism is a matter of degree. For lesser degrees of PE, we generally use long-term anticoagulation, but if there is a threat to life, it becomes urgent to remove the clot physically or by fibrinolysis. And then there is a middle category: “normotensive patients with intermediate-risk pulmonary embolism” who have evidence of cardiac strain but are haemodynamically stable. A large French trial randomized them to receive either tenecteplase plus heparin or placebo plus heparin. There was a non-significant reduction in death in the fibrinolytic group but a significant increase in major bleeds including stroke.
JAMA 9 Apr 2014 Vol 311
The New Cholesterol and Blood Pressure Guidelines: Perspective on the Path Forward (pg. 1403): Harlan Krumholz, who is on sabbatical leave, has only two important editorials in the top journals this week. His reflection on the new US Cholesterol and Blood Pressure Guidelines is a classic and needs to be downloaded by anyone interested in the future of medical practice. The radical importance of these latest guidelines is that they refocus attention on what guidelines are really for. Here is the conclusion: “While it is important to advocate for health and promote healthy environments and behaviors on the broader scale, for medical decision making, it is even more important to ensure informed choice with the full participation of the person who will incur the risks and benefits of the decision. When viewed through this lens, the controversies about the guidelines become less contentious and the focus shifts to refining the evidence and producing better ways to communicate what is known for decision-making purposes. By directing attention to that message, already firmly embedded in these guidelines with their bold recommendations and deference to patient preference, they may have accomplished more than they ever envisioned.”