March 30th, 2015
Selections from Richard Lehman’s Literature Review: March 30th
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 26 Mar 2015 Vol 372
Trial of Everolimus-Eluting Stents or Bypass Surgery for Coronary Disease (pg. 1204): Cabbage comes in and out of favour. I personally prefer the old fashioned kinds, such as Savoy or Sweetheart, cut in strips and stir-fried in nut oil with a few chopped walnuts, perhaps some shallot and bacon. Sprinkle with balsamic vinegar. I can’t get on with Cavolo Nero which has the texture and taste of a plastic bag, however you cook it. CABG started falling out of favour with the arrival of bare metal stents and even more with the allegedly superior drug-eluting stents. Here’s the first of the two trials in this issue. It was publicly funded in Korea and is open access. Recruitment was slow and the trial was terminated at two years. At that point, the composite end-point (grr) of death, myocardial infarction, or target-vessel revascularization had occurred in 11.0% of the patients in the PCI group and in 7.9% of those in the CABG group (absolute risk difference, 3.1 percentage points; 95% confidence interval [CI], −0.8 to 6.9; P=0.32 for noninferiority): not significant. Two years on, and the difference in favour of CABG had become just significant (CI 1.01 to 2.13; P=0.04).
Everolimus-Eluting Stents or Bypass Surgery for Multivessel Coronary Disease (pg. 1213): On to the next study, this time run by a stent manufacturer (Abbott Vascular) and behind a paywall. It’s a clinical registry study of 9223 patients with similar propensity scores who underwent PCI with everolimus-eluting stents and 9223 who underwent CABG. At nearly three years on average, the risk of death was the same. The risk of stroke was higher in the CABG group, while the risk of myocardial infarction or repeat revascularization was a bit higher in the stent group. This is the kind of study which cries out for replication by reanalysing the same individual patient dataset. Even then, propensity scoring is no substitute for true randomization. As the editorial says, these two studies take us no further forward in being able to put informed choices before patients.
BMJ 28 Mar 2015 Vol 350
Short term exposure to air pollution and stroke: Somewhat better evidence links short term exposure to air pollution with acute stroke. There is a massive literature: out of 2748 articles, 103 satisfied the inclusion criteria for this meta-analysis, and its conclusions are based on a total of 6.2 million events across 28 countries. The bad gases are carbon monoxide, sulfur dioxide, and nitrogen dioxide, and particulate matter also looks like a culprit for bringing on stroke, both at <2.5 µm or <10 µm diameter. My lord, should you wish to be spared a stroke, you must avoid port wine, eat vegetables, and take exercise henceforth in your country estates. My fee will be 100 guineas.