September 22nd, 2014
Selections from Richard Lehman’s Literature Review: September 22nd
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.
NEJM 18 September 2014 Vol 371
Outcomes One Year After Thrombus Aspiration for Myocardial Infarction (pg. 1111): Sucking clots out of coronary arteries at the time of myocardial infarction sounds like a good idea, and the single centre TAPAS trial, published in 2008, reported a 40% reduction in all cause mortality at one year. Unfortunately it was not designed to measure this outcome, whereas the much bigger Swedish TASTE trial, reported here, was properly powered and better randomized. And would you know it, routine thrombus aspiration before PCI in patients with STEMI did not reduce the rate of death from any cause or the composite of death from any cause, rehospitalization for myocardial infarction, or stent thrombosis at one year.
Follow-up of Blood-Pressure Lowering and Glucose Control in Type 2 Diabetes (OL): The ADVANCE trial was one of the three published in 2007-8, which showed that intensive glucose lowering in established type 2 diabetes had no benefit on hard outcomes. But it was a complex factorial trial, and it also measured the effect of blood pressure lowering in this patient group using a fixed combination of perindopril and indapamide. Once the trial was completed, glucose and blood pressure control in all the groups quickly became similar. So this long term follow-up study is really measuring a “legacy effect” of the tighter control which was imposed many years ago (the median post-trial follow-up period is 5.9 years for blood pressure and 5.4 for glucose). There was no evidence that intensive glucose control during the trial led to long term benefits with respect to mortality or macrovascular events. But the odd thing is that, in contrast with other studies, the tight blood pressure group in this trial does show a small persisting mortality benefit.
JAMA 17 September 2014 Vol 312
Evaluation and Treatment of Older Patients With Hypercholesterolemia (pg. 1136): I’ve just attended the Preventing Overdiagnosis conference in Oxford and I am filled with reforming zeal. So I bridled at the title of this clinical review: Evaluation and Treatment of Older Patients With Hypercholesterolemia. No! and again No! They are people not patients, and there is no such thing as “hypercholesterolemia,” any more than there is such a thing as “hypertension”—there are just continuously distributed variables, which contribute to overall cardiovascular risk. But I was mollified when I read their sensible conclusion: “No RCT evidence exists to guide statin initiation after age 80 years. Decisions to use statins in older individuals are made individually and are not supported by high quality evidence.”
Lancet 20 September 2014 Vol 384
Cardiovascular Outcome Trials of Glucose-Lowering Strategies in Type 2 Diabetes (pg. 1095): It comes as a surprise to me that the Lancet will publish anything with my name on it, but John Yudkin has very kindly sneaked me in as co-author of a letter about cardiovascular outcome trials of glucose lowering strategies in type 2 diabetes. At the time of writing, this correspondence stream seems to have escaped the Elsevier paywall and I would urge you to read it if you can. A response from Rury Holman and colleagues seems to herald a new era of peace and collaboration in finding out the real effects of blood glucose lowering agents. This is exactly what people with diabetes need, and we should seize the opportunity.
The BMJ 20 September 2014 Vol 348
Mild Hypertension in People at Low Risk: While at the conference, I was struck by the number of people who volunteered that they had given up using the term “hypertension” and were keen to see it abolished. I think we should form a Society for the Abolition of Hypertension. Here is an article about mild hypertension in people at low risk that goes some way to explaining why, accompanied by an article by a patient who is fazed by all these seemingly random changes of medical opinion. Take any cardiovascular risk factor, and you see a fairly linear relationship between its level and the degree of risk. Then you put in an intervention that lowers the risk factor. Sometimes it lowers the risk. But in all cases there comes a point where the “disutilities” of the treatment outweigh any benefit, or no benefit is observed at all. At a population level, the treatment may postpone a particular form of mortality, but have no effect on overall mortality. We live a while and then die. We all want to live well, and sometimes have preferences about the way we want to die. So we should all judge for ourselves what treatment we take, based on the likelihood of personal benefit or harm. Nobody suffers from hypertension, but a lot of people suffer from the effects of treatment to lower blood pressure.