February 16th, 2015
Selections from Richard Lehman’s Literature Review: February 16th
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.
JAMA 10 Feb 2015 Vol 313
Blood Pressure Lowering in Type 2 Diabetes (pg. 603): A new systematic review of blood pressure lowering in type 2 diabetes raises deep questions about the purpose and direction of medical intervention in chronic risk states. I haven’t space even to list them here, but I would just like to propose two common scenarios. A Bangladeshi woman of 34 is found to have high blood sugar and raised BP in her third pregnancy: these persist and within two years she is on six different medications including increasing doses of insulin. Her BMI is 41, she does not speak English and usually attends the practice nurse with a family member. Secondly, a 73 year old white male was found to have a BP of 164/96 ten years ago and has been on two antihypertensive drugs since. He has also been taking metformin for 5 years and his HbA1c runs at about 8 and his BMI is 32. Now I just want you to ask yourself: what are the absolute risks of cardiovascular disease, blindness, amputation and renal failure and the absolute benefits of each element of management (including surgery and lifestyle change) in either of these people? How are you going to communicate them and achieve the goals that your patient would most like? Do these people in fact have anything in common except a pair of labels (“hypertension” and “type 2 diabetes”)? What real-life questions would you like to see answered by new forms of what we now call meta-analysis? This particular one concludes that: “Among patients with type 2 diabetes, BP lowering was associated with improved mortality and other clinical outcomes with lower RRs observed among those with baseline BP of 140 mm Hg and greater. These findings support the use of medications for BP lowering in these patients.”
The BMJ 14 Feb 2015 Vol 350
Trajectories of Risk After Hospitalization for HF, Acute MI, or Pneumonia: My happy week continues with cracker of a BMJ paper from another young doctor I’ve tried to encourage—the phenomenally able Kumar Dharmarajan from the Harlan Krumholz circle at Yale. These guys—Joe Ross, Kumar, Kasia Lipska, Erica Spaatz, Leora Horwitz, Behnood Bikdeli, Nicholas Downing—are going to change the face of medicine long after I have left the fray. We have reached a futility point in the way we deliver acute medical care. In they come and out they go: home if lucky, or to institutional care, or the morgue. And then the cycle continues: “Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia.”