March 9th, 2015
How Appropriate Are Appropriate Use Criteria for Coronary Angiography?
Harindra C Wijeysundera, MD, PhD
The CardioExchange Editors interview Harindra C. Wijeysundera about his research group’s use of registry data from Ontario, Canada, in applying the 2012 appropriate use criteria (AUC) for diagnostic catheterization to patients referred for coronary angiography who had no known history of coronary artery disease (CAD). The study and its accompanying appendix are published in the Annals of Internal Medicine.
THE FINDINGS
For the 48,336 patients in the final cohort, 58.2% of angiographic studies were classified as appropriate, 10.8% as inappropriate, and 31.0% as uncertain. In all, 45.5% of patients had obstructive CAD.
| Appropriateness for angiography |
% with obstructive CAD |
% revascularized |
| Patients with appropriate indications |
52.9% |
40.0% |
| Patients with inappropriate indications |
30.9% |
18.9% |
| Patients with uncertain indications |
36.7% |
25.9% |
THE INTERVIEW
CardioExchangeEditors: In your view, how accurately do the appropriate use criteria identify who should and who should not undergo coronary angiography?
Wijeysundera: The ultimate goal of our study was indeed to determine how well the AUC could guide patient selection. Unfortunately, our results suggest that although the AUC provides some insight, it is insufficient in isolation to select patients who either should or should not undergo diagnostic angiography. The rationale for that conclusion is that, in our study, although patients with appropriate indications were more likely than patients with inappropriate indications to have obstructive CAD, still almost 50% of the “appropriate” patients had normal coronaries. Most important, almost a third of patients with inappropriate indications had obstructive CAD, and 1 in 5 had disease severe enough for revascularization. Our study highlights the need to further refine the AUC to better guide patient selection.
Editors: Of the roughly 10% of patients whose coronary angiograms would have been deemed “inappropriate,” about 20% underwent revascularization. Did this surprise you?
Wijeysundera: This important finding did not surprise us, in that it reflects the fact that clinical decision making is often complex and not easily captured by explicit criteria such as the AUC.
Editors: How were you able to translate the chart data into AUC categories? How did you know you captured each category well?
Wijeysundera: We obtained all of our data from a clinical registry held by the Cardiac Care Network of Ontario, Canada. All patients who undergo cardiac procedures in the province of Ontario must have data entered into this registry. The data itself have been validated by selected chart audits. To place patients into the AUC categories, we used a computer algorithm as detailed in our paper. To ensure the accuracy of that categorization, we restricted our analyses to only 12 AUC indications (i.e., those for patients with suspected coronary artery disease). The full document contains 102 AUC indications covering the spectrum of acute coronary syndromes, previously documented CAD, valvular disease, and arrhythmias. By restricting ourselves to only 12 indications in a very explicitly defined population, we were able to apply a relatively simple algorithm to categorize patients. We then performed numerous checks within each of the final AUC groups to ensure that patients had been appropriately categorized.
Editors: Where can readers find the mapping? What were the numerous checks?
Wijeysundera: The mapping is part of the appendix to our paper. We did make a few assumptions that are explicitly explained in our methods section. Our checks involved looking at the characteristics of patients in each category to ensure that our algorithm placed patients as intended. We were reassured by the face validity of the categories. Ideally, we would have done chart abstractions in a subset of patients, but we did not have access to the charts.
JOIN THE DISCUSSION
How do Dr. Wijeysundera’s findings affect your perceptions of the appropriate use criteria for coronary angiography?
March 9th, 2015
Appropriate Use Criteria for Diagnostic Catheterization are Weak
Larry Husten, PHD
Appropriate use criteria (AUC) are designed to help make sure that medical procedures and interventions are performed in patients most likely to benefit and, in turn, are not performed on people unlikely to gain benefit. Now a new study published in Annals of Internal Medicine suggests that the AUC for one very widely performed procedure, diagnostic cardiac catheterization, can provide a very rough indication of when it should and should not be performed, but that a great deal more work needs to be done before the criteria can be considered broadly reliable.
Researchers in Canada analyzed data from 18 hospitals in Canada including 48,336 patients with no known history of coronary artery disease who underwent diagnostic catheterization. Using criteria established by the American College of Cardiology in 2012, 58.2% of the procedures were considered appropriate, 31% were uncertain, and 10.8% were inappropriate.
A key measure was the diagnostic yield, or the percentage of people with a significant finding requiring further action. The percentage of patients who were found to have obstructive CAD was 52.9% in the appropriate group, 36.7% in the uncertain group, and 30.9% in the inappropriate group. The percentage of patients with significant left main or triple-vessel disease was 16.5%, 8.7%, and 7.1%. A revascularization procedure was performed in 40%, 25.9%, and 18.9%.
“Angiography in patients with an appropriate indication was associated with improved diagnostic yield of obstructive CAD and left main or triple-vessel disease and more subsequent revascularization. However, a substantial proportion of patients with inappropriate or uncertain indications also had important CAD,” the authors wrote. “Our finding that angiography with appropriate indications detects a greater proportion of obstructive CAD offers support to the AUC. However, it is important to note that our study also shows that almost 42% of the patients with appropriate studies did not have obstructive CAD, more than 30% of those with studies classified as inappropriate had obstructive CAD, and almost 19% of those in the inappropriate category had subsequent revascularization within 90 days.”
“Unfortunately, our results suggest that although the AUC provides some insight, it is insufficient in isolation to select patients who either should or should not undergo diagnostic angiography,” said the senior author of the study, Harindra Wijeysundera, in an interview with the editors of CardioExchange. “Our study highlights the need to further refine the AUC to better guide patient selection.”
In an accompanying editorial, Jacob Doll and Manesh Patel ask: “What about the 47% of procedures rated appropriate that did not find obstructive disease? It is important to recognize that not all indicated angiographic studies uncover CAD. Rather, the appropriateness rating indicates that the clinical scenario is one for which evidence supports a benefit of performing invasive angiography. A finding of no CAD in a patient with a high pretest probability, with resultant avoidance of unnecessary medications and further testing, is a valuable result. Similarly, the finding of obstructive disease among some patients with procedures rated inappropriate is expected.”
CardioExchange editor John Ryan offered additional perspective on the study: “This is an important manuscript because it raises concerns about the role of appropriate use criteria in diagnosing coronary artery disease with angiography. It is concerning that although ~10% of coronary angiograms were deemed inappropriate by AUC, ~20% of these patients required revascularization, and ~7% had left main disease. Of note, this study excluded people with MI, ACS, valvular heart disease, known CAD, prior revascularization, and arrhythmia. So it is a very select cohort under study here. Therefore the generalizability of these findings to a U.S. population is uncertain, but it sheds light on the challenges facing physicians, payers, and patients, in deciding what is appropriate and inappropriate. It will be important to extend this analysis into other aspects of diagnostic testing, including the AUC laid out for stress testing and echocardiography, among others.”
Note: Comments on this news story are closed, but please join the discussion about this topic over at our interview with Harindra Wijeysundera, lead author of this study.
March 9th, 2015
The Coffee Conundrum – What Do You Say to Your Patient?
John Ryan, MD
This post continues our series “What Do You Say to Your Patient?” In this series, we ask members to share how they interpret a complex or controversial issue for patients. To review earlier posts, click
The following scenario stems from a recent study published in Heart, which finds that people who consume moderate amounts of coffee may be less likely to have atherosclerosis.
Your 55-year old female patient with hyperlipidemia and hypertension comes in for her annual follow up.
She is taking daily aspirin 81 mg and atorvastatin 20 mg, both for primary prevention. She also takes CoQ10, ginseng, and an herbal medication for her liver. She is not sure what the herbal medication contains but says it, “…keeps my liver healthy.” Her lipids are well controlled and she exercises for 20-25 minutes every day on an elliptical machine.
Your patient says she drinks two cups of coffee a day and adds cream and sugar to each cup.
She asks: “I recently heard that coffee could help prevent heart disease. Should I drink more per day?”
What do you tell your patient?
Do you advise her to alter the amount of coffee she drinks?
Do you discuss what she is adding to her coffee and how it might affect her risk?
March 9th, 2015
Selections from Richard Lehman’s Literature Review: March 9th
Richard Lehman, BM, BCh, MRCGP
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.
JAMA Intern Med Mar 2015
Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs (OL): “Do carry on Rx to reduce SBP below 130 in nursing home pts @JAMAInternalMed if you want to kill them” I wrote on Twitter a couple of weeks ago. This week it will have to be “Do carry on Rx to reduce SBP below 130 in cognitively impaired elderly @JAMAInternalMed if you want to worsen their dementia.” This study was conducted over a three-and-a-half year period in two Italian memory clinics. Low daytime systolic blood pressure was independently associated with a greater progression of cognitive decline in older patients with dementia and mild cognitive impairment among those treated with blood pressure lowering medication – as most of them were.
The Lancet 7 Mar 2015 Vol 385
Effects of BP Lowering on Cardiovascular Risk According to Baseline BMI (pg. 867): I could go on at great length about elevated blood pressure and its treatments from the differing perspectives of the population and the individual. Say that (like me) you are a bit fatter than you should be and have a slightly elevated blood pressure. What does the massive database held by the Blood Pressure Lowering Treatment Trialists’ Collaboration have to say about the best drugs for you/me to take? “We found little evidence that selection of a particular class of blood pressure-lowering drug will lead to substantially different outcomes for individuals who are obese compared with those who are lean.”
March 5th, 2015
Has Lab Testing Become a Blood Sport for Cardiac Surgery Patients?
Colleen G. Koch, MD
The CardioExchange Editors interview Colleen G. Koch, lead author of a study of the extent of blood testing in cardiac surgery patients at Cleveland Clinic. The article is published in the Annals of Thoracic Surgery and was covered in a recent CardioExchange news story.
THE STUDY
For 1894 patients who underwent cardiac surgery at the Cleveland Clinic from January through June of 2012, there were 221,498 laboratory tests. Of those tests (mean, 115 per patient), 40% measured arterial or venous blood-gas levels, 18% assessed blood coagulation, 14% were for a complete blood count, 13% were for metabolic panels, and 5% were for blood cultures. The cumulative median volume of drawn blood during a hospital stay was 454 mL per patient.
THE INTERVIEW
CardioExchange Editors: Any reason to think Cleveland Clinic is better or worse than most hospitals when it comes to testing cardiac surgery patients’ blood?
Koch: Hospital systems vary according to whether they have primarily surgical or medical hospitalizations, the proportion of critically ill patients who require an ICU stay, and patient complexity. Any hospital with a similar ratio of surgical-to-medical hospitalizations and a similar patient acuity (i.e., degree of patient sickness) is likely to have findings similar to ours. If phlebotomy volumes are in excess, the patient is more likely to develop anemia.
Interestingly, in a separate recent investigation, our group studied the percentage of patients who came into the hospital with a normal hemoglobin value (not anemic) and followed their hemoglobin levels throughout hospitalization until hospital discharge to see whether they developed anemia. Among roughly 188,000 patients with medical or surgical hospitalizations in the Cleveland Clinic Health System, more than 70% developed anemia in the hospital. We found that patients who developed hospital-acquired anemia had worse outcomes (Koch et al. J Hosp Med 2013; 8:506). Other investigations report the association between higher phlebotomy volume and development of hospital-acquired anemia, so in the current study we sought to determine the amount of blood drawn for laboratory testing (phlebotomy volume) in the patients we cared for who were undergoing heart surgery.
Editors: You suggest that patients ask questions about the necessity of tests. Is this practical in most cases?
Koch: Yes, patients should be empowered to become more involved in their care and ask questions. Specifically, they should ask whether a test is necessary, should it be done every day, and or can smaller-volume test tubes be used? Cleveland Clinic has become a role model as an organization that embodies “patient-centered care.”
Editors: What can be done to change this culture?
Koch: Change begins with caregivers becoming aware of how their practices and processes influence patient outcomes. Second, you cannot manage what you do not measure. If caregivers were more aware of the total amount of blood taken throughout the care continuum, and how development of anemia relates to patient outcome and resource utilization, they might change how they practice.
Editors: Should this be assessed during hospital certifications?
Koch: Interestingly, 20 years ago, development of infections during the course of hospitalization was an event that occurred not infrequently. With increased measurement and emphasis on the morbidity implications of hospital-acquired infections, this outcome is a current metric for in-hospital quality of care.
I can only imagine that hospital-acquired anemia, which has many contributing factors (excess phlebotomy volume among them), may be on the radar as a possible quality metric, similar to hospital-acquired infections. Hospital-acquired anemia increases hospital resource utilization (total charges, length of stay) and, more important, is associated with greater patient mortality. Our current paper reports an association between increased red-blood-cell transfusion and excess phlebotomy volume. Of note, RBC transfusions are also expensive and have associated morbidity and mortality complications.
JOIN THE DISCUSSION
Are Dr. Koch’s findings likely to affect how your institution approaches blood testing in cardiac surgery patients?
March 4th, 2015
Genetic Screening Test Could Identify People More Likely To Benefit From Statins
Larry Husten, PHD
A genetic risk score can identify people at high risk for coronary disease, according to a new report in the Lancet. The score can also help find those who are most likely to benefit from statin therapy.
The genetic risk score, derived from 27 single-nucleotide polymorphisms (SNPs), successfully identified individuals at highest risk for a cardiac event within a study population of some 50,000 people who participated in a large community-based cohort study or one of four randomized controlled statin trials. People in the highest quintile of genetic risk had a 70% greater risk for coronary heart disease than those in the bottom quintile. Similarly, statin therapy resulted in the highest relative and absolute risk reductions in those at highest risk.
“There is ongoing debate over which individuals should be allocated statin therapy to prevent a first heart attack,” said the co-first author of the study, Nathan O. Stitziel, in a press release. “Some have said we should be treating more people, while others say we need to treat fewer. As an example of precision medicine, another approach is to identify people at high risk and preferentially prescribe statin therapy to those individuals. Genetics appears to be one way to identify high-risk patients.”
March 4th, 2015
FDA: Testosterone Therapy May Pose Cardiovascular Risks
Physician's First Watch, CardioExchange Staff
Men who use testosterone products to treat low testosterone may be at increased risk for myocardial infarction, stroke, and death, the FDA cautioned on Tuesday. The agency is requiring a label change to warn of these risks and to clarify the approved uses for such products.
The action — which updates a drug safety communication from January 2014 — is based on studies that demonstrated a potential link between testosterone therapy and cardiovascular risks, and on contributions from an FDA advisory panel.
The FDA emphasized that testosterone products are approved only for treating low testosterone caused by medical conditions such as disorders of the brain, pituitary gland, and testicles. Benefits for age-related low testosterone haven’t been demonstrated.
– See more at: http://www.jwatch.org/fw109934/2015/03/04/fda-testosterone-therapy-may-pose-cardiovascular-risks#sthash.46ZoNISE.dpuf
March 2nd, 2015
Moderate Coffee Consumption Linked to Lower Coronary Calcium
Larry Husten, PHD
The relationship of coffee and cardiovascular disease has been difficult to assess. Although early studies found a possible increased risk associated with heavy coffee consumption, more recent studies have found the opposite. Now a new study published in Heart finds that people who consume moderate amounts of coffee may be less likely to have atherosclerosis.
In a study of more than 25,000 people in South Korea without known cardiovascular disease, researchers examined the relationship between various levels of coffee consumption and the coronary artery calcium (CAC) score as measured by a multidetector CT scan. They found that people who drank coffee were less likely to have calcium in their coronary arteries than nondrinkers. They described the relationship as U-shaped, with the lowest levels occurring in the people who drank 3 or 4 cups of coffee each day. The overall pattern remained present after multiple analyses adjusting for risk factors.
“Our findings are consistent with a recent body of literature showing that moderate coffee consumption may be inversely associated with cardiovascular events,” the authors wrote. But they concluded that “further research is warranted to confirm our findings and establish the biological basis of coffee’s potential preventive effects on coronary artery disease.”
Despite the recent positive findings, the senior author of the study, Eliseo Gualiar, an epidemiologist at Johns Hopkins, said in an email that he was “concerned that the role of coffee in preventing cardiovascular disease is exaggerated. Our study was an observational association study that by itself cannot prove causation.” However, Gualiar said the findings were “reassuring, in the sense that coffee intake, a very common habit, is not associated with increased cardiovascular risk.” Moderate coffee drinkers, he said, “should not be concerned that coffee is increasing their risk of cardiovascular disease. On the other hand, we believe that at this point we should still not recommend drinking coffee for preventing cardiovascular disease.”
Yale University cardiologist Harlan Krumholz said he agreed with Gualiar: “It is important that the public interpret this study in that context. People should not feel an imperative to drink coffee to lower risk, but those who enjoy coffee may take comfort in a study that failed to identify a risk and even suggested a benefit.”
Gualiar’s perspective was also largely endorsed by another expert not involved with the study, Thomas Whayne Jr., a cardiologist at the University of Kentucky, who disclosed that he is “a major fan of coffee as my favorite beverage.” “The bottom line,” he says, “is that, for the patient who loves coffee in moderation, there should be no restriction to moderate intake even in the severe heart-failure patient, and patients should be encouraged to enjoy coffee unless there were to be an unpleasant association with something such as increased arrhythmias.” Whayne said that cardiologists “should not recommend coffee, even in moderation, to prevent coronary atherosclerosis” but that they can reassure patients that there may be some benefit and, at worst, very little cardiovascular risk.”
March 2nd, 2015
How Can We Care Better for Patients Even After They Leave the Hospital?
Joy Pollard, PhD, ACNP-BC
The CardioExchange Editors interview Joy Pollard about her research group’s findings in her recent paper studying the impact of regional collaboratives on improving heart-failure readmission rates. The article is published in the Journal of Nursing Care Quality.
CardioExchange Editors: Would you please summarize your findings for our readers?
Pollard: Using a focused, collaborative method concentrated on improving seven day post-discharge follow up and reducing 30-day heart failure readmissions, 10 hospitals in Southest Michigan showed improvement in both follow-up and readmission rates greater than non-participating hospitals in the same region. This Quality Improvement project was a year-long forum intended to bring hospitals together to learn from each other and share best practices and improvement strategies. Collaborative hospitals represented both urban and suburban hospitals and were affiliated with multiple health care systems. Each hospital had varying degrees of both supportive resources and maturity of their heart failure programs. Using aggregate claims data for Medicare fee-for-service beneficiaries provided by the Michigan Peer Review Organization, results showed overall 30-day readmission rates were reduced more in the collaborating hospitals than in non-collaborating hospitals (from 29.32% to 27.66% vs. from 27.66% to 26.03%; P=.008).
Editors: How did you establish the Southeast Michigan “See You in 7” Hospital Collaborative, and what was the role of ACC in this collaborative?
Pollard: The collaborative was a joint venture of the Greater Detroit Area Health Council in partnership with the American College of Cardiology (ACC) and the Michigan Peer Review Organization. The emphasis in this project was to implement strategies from the ACC Hospital to Home tool kit “See You in 7” challenge. Hospital to Home is a comprehensive Quality Improvement initiative of the ACC that provides evidenced-based tools for navigating the complexities of reducing readmissions for heart failure patients. Hospitals completed a “See You in 7” self-assessment before the collaborative as a gap analysis to identify individual areas of improvement. Each hospital then identified metrics from the toolkit on which to focus their process improvement. During the year-long project, hospitals tracked progress on their metrics and submitted quarterly process improvement reports that identified their successes and barriers in reaching their goals. Hospitals shared their quarterly reports in a round table format. Collaborative hospitals made modifications to their internal processes, established multidisciplinary teams to interview patients and families, improved their own data collection and tracking, streamlined availability of discharge summaries to follow up providers, identified key elements needed in discharge summaries, and created transportation guides to address patient barriers to follow up access.
Editors: What are the next steps? Have the hospitals sustained these efforts since this study was completed?
Pollard: Post-collaborative sustainability efforts by hospitals have focused on strategies that incorporate differing members of the care team into systematic improvement. One hospital now has every HF patient meet with a pharmacist (or pharmacy student) at their seven day follow up appointment for medicine reconciliation and teaching. Establishing support from the hospital administrative team has been another area of focus, with most utilizing a multidisciplinary approach of physicians and nurse champions meeting with administrators, quality management, and directors in tracking their progress. Overall, there was no mechanism for structured follow-up after the end of the year-long collaborative initiative. This limitation was due in part to ending of funding by the Robert Wood Johnson Foundation to the Greater Detroit Area Health Council, who supplied the collaborative with meeting space, electronic communication, and webinar support.
Next steps include extrapolating lessons learned from the MI collaborative to other regions and using a wider scope of the Hospital to Home toolkits in reducing heart failure readmissions.
March 2nd, 2015
Selections from Richard Lehman’s Literature Review: March 2nd
Richard Lehman, BM, BCh, MRCGP
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.
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?
NEJM Journal Watch — Recent Cardiology Articles- To Lower Stroke Risk in Patients Undergoing Atrial Fibrillation Ablation, Is a Device or a Medication Better?
- Intensive vs. Standard Blood Pressure Lowering in Patients with Diabetes
- Anticoagulation in Patients with Cancer-Associated Pulmonary Embolism: How Long is Long Enough?
- Spironolactone Use After Percutaneous Intervention for Acute Myocardial Infarction
- CRISPR/Cas9 Gene Editing for Transthyretin Cardiomyopathy