April 20th, 2015

Selections from Richard Lehman’s Literature Review: April 20th

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 16 April 2015 Vol 372

Efficacy and Safety of Alirocumab in Reducing Lipids and Cardiovascular Events (pg. 1489): Your learning task this week is to memorise “proprotein convertase subtilisin–kexin type 9 (PCSK9).” The next big lipid lowering debate will be all about inhibitors of PCSK9, and somebody should urgently invent a popular name for them. I suggest fatins (fat lowering injections), to rhyme with statins. There are two of them at the moment: alirocumab and evolocumab. In this trial, alirocumab was given as an injection every two weeks to two thirds of 2341 patients at high risk for cardiovascular events who had LDL cholesterol levels of 1.8 mmol per litre or more and were receiving treatment with statins at the maximum tolerated dose. The rest had a placebo injection. “At week 24, the difference between the alirocumab and placebo groups in the mean percentage change from baseline in calculated LDL cholesterol level was −62 percentage points (P<0.001); the treatment effect remained consistent over a period of 78 weeks.” The trial was not powered to detect a fall in actual cardiovascular events over this period, but as its name ODYSSEY LONG TERM implies, it means to go on: To strive, to seek, to find, and not to yield. (Last line of Ulysses by Tennyson)

Efficacy and Safety of Evolocumab in Reducing Lipids and Cardiovascular Events (pg. 1500): And now for fatin number two. Evolocumab is a monoclonal antibody that inhibits proprotein convertase subtilisin–kexin type 9 (PCSK9), as you already know: the phrase is already tripping off your tongue. This is Amgen’s answer to Sanofi and Regeneron’s alirocumab, and it has chosen to call its trial OSLER. The effect of the two antibodies seems to be very similar. Again, the early signals point to a substantial fall in cardiovascular events, but only time will tell. This will be a hard fight, but it isn’t clear how big the potential market will be. After all, the real Osler is quoted as saying “The first duty of the physician is to educate the masses not to take medicine.” The statins wars will soon become the fatins wars; and I hereby declare copyright on the word fatin. I am willing to sell this to either drug company for a million dollars. Everyone has their price and mine is very reasonable.

JAMA 14 April 2015 Vol 313

Survival and Outcomes Following Bioprosthetic vs Mechanical Mitral Valve Replacement in Patients Aged 50 to 69 Years (pg. 1435): I have a kind of déja-vu feeling about this report on 15 year outcomes in “nonelderly” patients with mitral disease requiring valve replacement who have been treated with either bioprosthetic and mechanical prosthetic valves. Maybe it’s because I have read too much cardiac outcomes research, or because I am approaching the end of nonelderliness. Anyway, in patients aged 50 to 69 years undergoing mitral valve replacement in New York State, there was no significant survival difference at 15 years in patients matched by propensity score who underwent mechanical prosthetic vs bioprosthetic mitral valve replacement.

Acute Stroke Intervention (pg. 1451):Acute stroke intervention: a systematic review” is a very good update article because it goes a bit further and wider than simply a systematic review. This is a really fast moving subject, and the necessary rush to get patients assessed and treated means that primary care doctors are not involved except occasionally to ring for a blue light ambulance on behalf of the patient. But it’s an area of interest to everyone, since anyone can have a stroke. The two studies of thrombectomy that I recently commented on are still sitting on the NEJM website, and it’s only a week or two since a paper appeared which should be practice changing in a different way. This describes a computerised decision aid, which can help patients and their relatives make very fast decisions about thrombolysis on an individualised basis. It was developed in Newcastle (UK) and every stroke unit around the world needs to know about it.


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