March 2nd, 2015

Selections from Richard Lehman’s Literature Review: March 2nd

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.

JAMA 24 February 2015 Vol 313

Association of NSAID Use With Risk of Bleeding and CV Events in Patients Receiving Antithrombotic Therapy After MI (pg. 805): It’s taken a curiously long time for anyone to be worried about the cardiovascular harms of non-steroidal anti-inflammatory drugs. I can remember first discovering that diclofenac carried a bigger cardiovascular risk than cigarettes about 15 years ago, and finding it hard to believe; then along came the rofecoxib (Vioxx) affair, which revealed that pharma companies had long been aware of the problem but had succeeded in sweeping it under the carpet. A new observational study from Denmark raises the question of whether anyone with known cardiovascular disease should ever be prescribed a NSAID other than low dose aspirin. They looked at the entire post myocardial infarction population. “The multivariate adjusted Cox regression analysis found increased risk of bleeding with NSAID treatment compared with no NSAID treatment (hazard ratio, 2.02), and the cardiovascular risk was also increased (hazard ratio, 1.40). An increased risk of bleeding and cardiovascular events was evident with concomitant use of NSAIDs, regardless of antithrombotic treatment, types of NSAIDs, or duration of use.”

Association Between Sauna Bathing and Fatal CV and All-Cause Mortality Events (OL): In the course of world history, many cultures have developed methods of hot bathing, but none so ardently as the Finns, who regard sauna bathing with national pride. I am not really sure from the description in Wikipedia that sauna bathing is really a form of bathing at all: it sounds more like just sweating profusely, naked in an overheated room. I fear I shall probably die without ever trying it, and die sooner as a result. Back in the 1980s, a cohort of 2315 middle aged men was recruited in eastern Finland. A total of 601, 1513, and 201 participants reported having a sauna bathing session one time per week, two to three times per week, and four to seven times per week, respectively. Disturbingly, that comes to 2315, meaning that not a single one of these Finns escaped the heated room. Now the results: “After adjustment for cardiovascular disease risk factors, compared with men with one sauna bathing session per week, the hazard ratio of sudden cardiac death was 0.78 (95% CI, 0.57-1.07) for two to three sauna bathing sessions per week and 0.37 (95% CI, 0.18-0.75) for four to seven sauna bathing sessions per week (P for trend = .005). Similar associations were found with CHD, CVD, and all cause mortality (P for trend ≤.005).” Golly. If you spent enough time sweating in one of these rooms, you would probably become immortal.

Lancet 28 February 2015 Vol 385

Standard vs. AF-Specific Management Strategy (SAFETY) to Reduce Recurrent Admission and Prolong Survival (pg. 775): If you want to make a lot of money out of a product, you talk it up. So most weeks I have to point out the hype in an industry funded trial of a new drug or device. And equally, if you put lots of effort and good intentions into a complex intervention that you believe should work, you talk it up. So most weeks I have to point out the hype in a non-industry funded trial of a novel system of care. Here, the main part of the intervention was a cardiac nurse who visited patients 7-14 days after a hospital admission related to atrial fibrillation without heart failure. “The nurse used the GARDIAN (green, amber, red delineation of risk and need) method to assess every individual’s holistic circumstances [sic] and ability to self-care, to delineate their management according to clinical status and expert guidelines.” Result in the text: “No difference between the SAFETY intervention and standard management was discernible for readmissions for atrial fibrillation, cardioversions, a fall, bleeding events, acute coronary syndrome, and cerebrovascular events. Fewer admissions for de-novo heart failure were noted in patients allocated to the SAFETY intervention group compared with those assigned to standard management (18 [11%] vs 28 [17%]; p=0•115).” So this was an essentially negative study except for the difference in a single one of seven endpoints. The conclusion of the abstract puts it like this: “A post-discharge management programme specific to atrial fibrillation was associated with proportionately more days alive and out of hospital (but not prolonged event free survival) relative to standard management.” Er, um, why conflate “alive” and “out of hospital” and then take out event free survival? Why not just say that a few more people in the usual care group got admitted with heart failure? I suspect that it was because this was not a prespecified secondary outcome. And if you look at the event free survival chart (Fig 2) you’ll see that for the first two years of the trial, people receiving usual care actually did better.

Cardioverter Defibrillator Implantation Without Induction of Ventricular Fibrillation (pg. 785): It’s all cardiology in this week’s Lancet. Boston Scientific make implantable cardioverter-defibrillators and helped to fund a study, which compared testing them in patients by inducing ventricular fibrillation with not testing them in this shocking way. It made no difference to improving efficacy or preventing arrhythmic death.

Extended Duration Dual Antiplatelet Therapy and Mortality (pg. 792): Next: a systematic review and meta-analysis confirming that extended duration dual antiplatelet therapy is not associated with a difference in the risk of all cause, cardiovascular, or non-cardiovascular death compared with aspirin alone or short duration dual antiplatelet therapy.

The War Against Heart Failure (pg. 812): And now for Eugene Braunwald’s Lancet lecture: “The war against heart failure.” Ouch. That sounds awfully like Richard Nixon’s war on cancer. My usual lecture on heart failure is called “Hating heart failure,” but fiercely as I hate the condition and its label, that is no declaration of war. Braunwald is sensible enough to admit that heart failure is quite often the price of success in keeping more people alive longer with damaged hearts. It is a mode of death. And while fighting death at all costs may be appropriate in younger people, there comes an age when it is better to accept it as inevitable and concentrate on reducing its distress. War is nothing but the unleashing of massive evil in the hope of eventually outweighing it with long term benefit: in which it rarely succeeds. Fortunately, the weapons against heart failure are not especially evil, but they are often badly deployed. Patients are often the victims of friendly fire. Soon there may be more weapons, offering more opportunities for futility and harm as well as success. They will tinker with myocyte function at the level of the calcium transfer gene, perhaps: in an echo of the Lord of the Rings, we may soon call up the antagomirs (sons of Faramir and Boromir?); and unfazed by more than a decade of failure, Braunwald still believes that stem cells will one day be taken off the shelf and used to regenerate myocardium. I hope so: but in the meantime, millions of old people with a high disease burden will seek relief from what they know is an in inevitable slide towards death. Their war is over. How can we help them to die less awfully?


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