CardioExchange Archive

CardioExchange is pleased to reprint selections 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.

Week of March 19th

NEJM  15 March 2012  Vol 366

Percutaneous Patent Foramen Ovale Closure (pg. 991):  In my last year as a proper GP, I presented two cases from my practice of young women who had suffered cryptogenic stroke and had been found to have patent foramen ovale. OK, foramina ovales. I gathered together myself and a GP partner and a local stroke doctor and some interventional cardiologists from Oxford, and we had a high old time congratulating ourselves on our diagnostic acumen while the receptive audience admired real-patient videos showing the technical wizardry of percutaneous PFO closure. Clearly, we had saved these ladies from the dangers of recurrent stroke by the timely deployment of sophisticated interventions based on impeccable mechanistic insight. But even during the presentation, there was a slight feeling of unease when the evidence base for this presumption was interrogated: PFOs can be found in 25% of the population and there didn’t seem to be an adequately powered study to compare device closure of PFOs with medical therapy. Well, now there is, with a follow-up period of two years, and there is no difference in outcomes so far. So while I was trying for one last time to share some of the glamour of sophisticated sexy medicine, perhaps all that these patients needed was what I had tried to provide them with for the whole of my working life – good primary care.

Arch Intern Med  12 Mar 2012  Vol 172

Dabigatran Risks (pg. 397): About ten years ago, I advised you to train your larynx to pronounce the word ximelagatran, the name of the first direct thrombin inhibitor which seemed poised to replace warfarin for numerous clinical indications. If you followed my advice, you abraded your vocal cords and twisted your palate to no avail, since the drug was withdrawn in 2006 following reports of hepatotoxicity. Its successor dabigatran is easier to pronounce, works well at a fixed dose, and generally seems harmless to the liver. Boehringer Ingelheim seemed to have a winner on its hands. But alas, a cloud no bigger than a man’s hand has appeared on the horizon. Here is a meta-analysis which shows that dabigatran is associated with an increased risk of MI or ACS in a broad spectrum of patients when tested against different controls, and that is not something one likes to hear about a drug designed for long term thromboprophylaxis.