Consider The Evidence: Med/Peds Journal Roundup

August 24, 2006

Can UF Heparin replace LMWH as subcu anticoagulation?

Filed under: JAMA, VTE — medblog @ 8:30 pm

JAMA 8/23 – Will Lovenox and Fragmin share the same fate as New Coke? A study by Kearon et al. investigated the use of Classic unfractionated heparin as a subcutaneous treatment without APTT monitoring. The study protocol treated DVT and PE with a twice daily subQ injection of UFH in much the same way Low Molecular Weigh Heparin is used currently, except for a weight adjustment. The results essentially show that UFH was equally effective as LMWH in preventing recurrent thromboembolism. Appparently the crazy unpredictable pharmacokinetics are not a big issue with the subcutaneous route. And the fact that UFH is about 50 times cheaper is a big plus.
The study was an open-label RCT and the outcome analysis was done by blinded investigators. About 70% of subjects were treated as outpatients. Apparently there were some problems with recruitment but the power was adequate to provide reliable results.

August 23, 2006

Even more uses for ACE-I’s

Filed under: cardiovascular, hypertension, lancet — medblog @ 7:14 am

Lancet 8/19 – Updated guidelines for Abdominal Aortic Aneurysm screening were put out by USPTF last year reccommending ultrasound in men aged 65-75 who have ever smoked, especially due to the mortality and lack of medical treatment options for the disease. Clearly endovascular pathology related to atheroma and smoking are somehow involved. with AAA.
Enter ACE-inhibitors, which seem to be showing evidence of vasoprotective effects through some modulation of the renin-angiotensin system – also thought to be involved somehow with vascular pathology.

Hackam et al. publish a retrospective observational study in the current Lancet, investigating the use of ACE-I’s in patients with AAA. They analyzed records of 15,000 patients hospitalised with a primary diagnosis of abdominal aortic aneurysm in Canada. The researchers found that patients receiving ACE inhibitors before admission were significantly less likely to present with aortic rupture.(Adjusted Odds Ratio: 0.83) They conclude that the beneficial effect of such drugs is independent from their antihypertensive properties, because use of other antihypertensive agents was not associated with a lower risk of AAA. Clearly the study comes with all of the shortcomings of a retrospective study, and although we cannot conclude a causal effect, RCTs are warranted.

August 15, 2006

ACE-Is: ACE in the hole for atherosclerosis

Filed under: Cardiology, cardiovascular, lancet — medblog @ 11:12 pm

Lancet 8/12 – ACE inhibitors initially hit the big time due to two clearly beneficial effects: reduction of ventricular remodeling in heart failure, and renal protection in diabetes with hypertension. These studies also suggested ACE-inhibitors have some overall cardiovascular benefit independent of BP lowering and correction of heart failure. Could ACE inhibitors join statins as a class of drugs with multiple vascular benefits beyond the main mechnism it has traditionally known for??

Effects of ACE-Is were studied in the landmark trials HOPE, EUROPA and most recently PEACE. Dagenais et al.published an article looking at these three trials for statistical evidence of benefit in patients with atherosclerosis. And they found it: overall in the three trials, patients without heart failure on ACE therapy had significant risk reductions in cardivascular mortality, acute MI, and stroke. Each effect had an absolute risk reduction around 1%. Small, but significant.

Statins + ACE-inhibitors = crazy delicious.

August 3, 2006

Actually useful research on dieting?

Filed under: archives of internal medicine, diet, obesity — medblog @ 12:46 pm

ArchIM 6/24 – It is rare enough to see an RCT involving diets, but rarer still to see one with useful results. A study by McMillan-Price in last week’s Archives addressed the issue of diet content. Favor has recently fallen on low glycemic index foods and high protein content. But does this strategy make a difference in weight loss? Yes and No.

The study design divided subjects into 4 groups. Two were high in protein, and two high in carbohydrates. Each pair consisted of a high and low glycemic index group. The overall weight lost was similar in all groups. Bummer, this is starting to look like every other diet trial…

However, LDL levels declined the most in the high-carb, low-glycemic index group, and increased in the high protein, high – GI group. BUT the women in that group (high-protein, high GI) had the greatest number of subjects that lost more than 5% of body weight.

So maybe for women there is something to the Atkins idea as far as weight loss, but this is offset by an increase in cardivascular risk factors(LDL).

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