April 9th, 2015

Selections from Richard Lehman’s Literature Review: April 9th

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 2 April 2015 Vol 372

Outcomes of Anatomical vs. Functional Testing for Coronary Artery Disease (pg. 372): In English nursery rhyme, it is traditional for a Duke to have 10 000 men. Here is a trial from Duke University that recruited 10 000 men and women, and allowed in a further three for extra measure. These 10 003 recruits were those “whose physicians believed that nonurgent, noninvasive cardiovascular testing was necessary for the evaluation of suspected coronary artery disease.” That is a fate which befalls a staggering four million Americans every year. These people were randomised to be investigated either by coronary computed tomographic angiography or functional testing, which in almost every case meant exercise ECG. I struggled a little with some of the figures, but I broadly agree with the conclusion: “In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of two years.” But I do just wonder how many of these people really “required” testing in the first place.

Oh, the PROMISE trial of Duke,
It had 10 000 men;
They marched them up on a treadmill test,
Or they scanned their arteries then.

And when they were clear, they were glad,
And when they were blocked, they were down,
And when they were only halfway blocked,
They were neither glad nor down.

Nobody knows the meaning of the original nursery rhyme, and I’m not sure I know the meaning of this trial either.

Demographic and Epidemiologic Drivers of Global Cardiovascular Mortality (pg. 1333)”: That’s the kind of topic the Lancet is good at dealing with—much better, it turns out, than the NEJM. You need a big long article with lots of charts that you can play with. And it should be open access too: I thought the Bill & Melinda Foundation insisted on that. But this over compressed, under illustrated piece is behind a paywall. And you’re not missing much if, like me, you are interested in the age and social class distribution of cardiovascular disease in individual countries and what may lie behind these. I’m aware that there are numerous intriguing paradoxes, but this article doesn’t have the detail to help you find or understand them. A missed opportunity.

JAMA April 2015 Vol 313

Efficacy of Folic Acid Therapy in Primary Prevention of Stroke Among Adults With Hypertension in China (OL): A Chinese trial in people with elevated blood pressure raises the intriguing possibility that supplemental folic acid may reduce stroke. They recruited over 20 000 adults and gave them enalapril alone or enalapril plus 0.8mg of folic acid and followed them up for a median 4.5 years. The absolute risk reduction for first stroke between the groups was 0.7%, which on an individual level seems trivial: but if you look at this from a long term population perspective, this 20% reduction in relative risk might result in millions fewer strokes in China. This calls for replication in different populations. And is one more reason to put folate in bread, or rice.

JAMA Intern Med April 2015 Vol 175

Primary Results of the Patient-Centered Disease Management for Heart Failure Study (OL): Next week I’ll be putting my head above the parapet and giving a couple of short talks at Evidence Live. One of them will be about how we try to fit patients to the evidence and the outcomes we want: it is so much simpler than seeing how much of the evidence actually applies to each individual and corresponds with the outcomes they want. My illustration will be heart failure. The median age of patients is 76 or more, they have other illnesses—including whatever caused their heart to fail—they are tired and scared. They know they are going to die, most probably from pulmonary oedema, and many of them have experienced how distressing and protracted that can be. The majority would rather have better symptom relief than a longer life. And they want a place of comfort and safety when they die, not rushed treatment in a noisy ward where they are just another old person with HF. One way to tackle this would be to provide them with patient centred disease management at home, and this was the laudable aim of John Rumsfeld’s PCDM trial reported here. But the terse conclusion reads: “This multisite randomised trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care.” It is laudable that the authors chose this as their primary outcome measure and stuck with it. Had mortality been the criterion, this trial would have been a success. And levels of depression were significantly lower in the intervention group. Let’s build on this great work and see if we can do better. We owe it to these millions of people ending their lives in distress.

The BMJ 4 April 2015 Vol 350

Precision Medicine to Improve Use of Bleeding Avoidance Strategies and Reduce Bleeding in Patients Undergoing PCI: The curmudgeonly old fart in me bridles at the phrase “precision medicine,” but on reflection it is an aspiration that I share. And seeing John Spertus’s name on this paper is a guarantee that at least this one is going to be good. The only time I ever saw patients immediately after percutaneous coronary intervention was when they came to me with big groin haematomas. Bleeding after PCI is a problem that lends itself to precision medicine, because you can calculate personalised risks using the Patient Risk Information Services Manager (ePRISM). So in your highest risk patients, you try to avoid the groin and go into the radial artery instead, and use bivalirudin and perhaps a closure device. I leave the details to any interventional cardiologists who are reading this. And this strategy did reduce bleeding when it was adopted, although “Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care.” Cardiologists, honestly.

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