Consider The Evidence: Med/Peds Journal Roundup

April 14, 2007

Preventing Post-Op A-fib

Filed under: Cardiology, JAMA — medblog @ 9:50 am

JAMA 4/11/07 – A rare surgery related article for today by Halonen(s) et al. from JAMA.

For unclear reasons the incidence of A-fib after CABG and valve surgery is pretty high (20-40%). One theory is that it is somehow related to an inflammatory response,  and maybe can be prevented with steroids.

This double blind RCT compared Q8 hr hydrocortisone for 3 days postop to placebo for the incidence of atrial fibrillation. They found the incidence of postoperative AF was significantly lower in the hydrocortisone group (30%) than in the placebo group (48%)  with a NNT of 5.6.  And the incidence of infection was similar in both groups.

Interesting because I remember blogging about an article that showed an increase in A-fib with pulse dose steroids in Annals last year. What gives? Well the prior study didnt involve surgery and it was observational – but I was still suprised at the opposite conclusions…. hopefully it will become more clear when the exact mechanism is better worked out

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February 20, 2007

Statins and Heart Failure

Filed under: Cardiology, statins — medblog @ 3:06 pm

Circulation 2/6 – Treating to New Targets (TNT) was one of many recent statin trials investigating the utility of high-dose treatment with very low LDL-C goals for improving cardiac outcomes. In a recent issue of Circulation Khush et al. published a subgroup analysis of data related to exacerbations of heart failure among trial participants. The study examined the number of hospitalizations for heart failure among the subjects in both the intervention (high dose atorvastatin) and control (usual dose atorvastatin) group.

The investgators found that those with CHD were about 26% less likely to be hospitalized for HF in the intervention arm. Those with CHD and prior CHF were 41% less likely to be hospitalized for an exacerbation. The authors of the study noted that in most cases there was no preceeding ischemic event such as MI or UA prior to the exacerbation. This led them to conclude that the protective effect in heart failure is not simply from the reduction of coronary stenosis alone, but rather an independent effect of statins on heart failure.

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.

July 28, 2006

MDCT not quite ready for CAD screening

Filed under: Cardiology, JAMA — medblog @ 9:49 pm

JAMA 6/26 – Interventional radiologists can breathe a little easier…. for now. A study by Garcia and the CATSCAN investigators in JAMA explored the use of 16 row multidetector CT to assess for coronary artery stenosis. Having a non-invasive method to evaluate the condition would make life much easier for many thousands of CAD sufferers each year, not to mention fattening some radiologist pocketbooks.

But unfotunately, in a study of over 200 patients, the test was only moderately (89%) sensetive and not very specific (65%) in the detection of greater than 50% stenosis. In addition, only 71% of the lesions were evaluable. Clearly not ready for primetime yet, but the technology is probably not that far off.

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July 5, 2006

N-acetylcysteine for Contrast Nephropathy Re-revisited

Filed under: Cardiology, NEJM, renal — medblog @ 10:20 am

NEJM 6/29 – The use of N-Acetylcysteine for contrast nephropathy has been so extensively studied, there are actually meta-analyses of meta-analyses on the subject. And even after all that, the evidence for N-Acetylcysteine for prevention of contrast nephropathy is still pretty much equivocal. For every study that shows a benefit, there is another that shows no benefit at all.

An article in the New England by Marenzi et al. adds weight to the pro-NAc side of the argument. The RCT specifically looked at primary angioplasty and the incidence of contrast nephropathy after the procedure. About 300 subjects were randomized to recieve Low dose NAc, high dose NAc or placebo. According to the study, there was a significant lowering of the incidence of nephropathy with the use of NAc, with the greatest effect in the high-dose group.

Although all patients were hydrated after treatment, I did not find whether the placebo group received a fluid bolus as a control for the NAc solution. Could the effect be related to the extra hydration from the medication solution rather than the NAc itself?

May 9, 2006

Corticosteroids and Atrial Fibrillation

Filed under: archives of internal medicine, Cardiology — medblog @ 11:48 am

Archives IM 5/9 – van der Hooft et al. investigate the theory, based mostly on case reports, that high-dose pulse steroid are associated with in an increased risk of Atrial-fibrillation (AF).

The study was a case-control design, with patient data from the Rotterdam Study. Subjects were categorized as receiving either high dose or low/moderate dose steroids.
The odds ratio for developing new onset AF with 1 month of starting therapy was 6.07 compared to controls, whereas the odds from the low/moderate dose group was not significantly different.

The risk was independent of indication, which is reassuring. However, I wonder whether the use of high-dose steroids indicates a greater severity of disease which may be correlated with a generally increased risk of cardiac complications?

March 20, 2006

Plaque-busting with statins

Filed under: Cardiology, JAMA, statins — medblog @ 11:14 pm

JAMA 3/13 – Nissen et al. produce the latest, and largest of several trials documenting the effect of statin therapy on atherosclerotic plaques. The earlier studies suggested that intensive therapy with statins led to the decrease in atheroma volume. The authors of this study contend that their measurement parameters (taken via IVUS) were more rigorous than the past studies, allowing them to make a much more definitive conclusion on the issue.

A dramatic result of the study was the reduction median LDL-C levels by over 50% to approx 60mg/dl.“The achieved LDL-C levels were the lowest values ever observed in a statin atherosclerosis progression trial.” The mean change in atheroma volume in the most diseased 10-mm subsegment was –6.1 mm3. Change in total atheroma volume showed a 6.8% median reduction; with a mean reduction of –14.7 mm3. They conclude that, “When viewed in this context, the results of the current study demonstrate that there exists no apparent threshold LDL-C level beyond which the benefits of statin therapy are no longer evident. If regression of disease is the desired outcome, then lower LDL-C is better.”

Put them in the water…..

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February 28, 2006

G-CSF can’t stem the tide of Acute MI

Filed under: Cardiology, JAMA, myocardial infarction, stem cells — medblog @ 10:45 pm

JAMA 3/1 – Disappointing results from Zohlnhofer et al. in this weeks’ JAMA from a trial utilizing G-CSF to mobilize stem cells after acute MI (free full text avail.) Although some preliminary studies were promising, this is the first true RCT to address the subject. The researchers administered G-CSF 5 days after infarct and then followed up patients with T-99 scintigraphy, MRI, and/or angio. Although a significant increase of CD34+ cells was detected, indicating a surge of stem cells was mobilized – there was no significant difference in LVEF or infarct size at follow up. . . (more…)

February 20, 2006

Facilitated PCI a bust yet again

Filed under: Cardiology, lancet, myocardial infarction, PCI — medblog @ 3:22 pm

Lancet 2/20 – There has been some buzz of late about facilitated percutaneous coronary intervention (PCI) – using fibrinolytics before going to the cath lab in order to increase the critical 2-3 hour window of opportunity for reperfusion. An article by the ASSENT4-PCI group in this weeks Lancet adds to the data that such a strategy is not beneficial. (more…)

February 4, 2006

Risk score for stable angina – Euro heart study

Filed under: BMJ, Cardiology — medblog @ 3:47 pm

BMJ 2/4 – Isnt the Framingham score all we need in predicting cardiovascular outcomes? Apparently not according to this study by Daly et al. in this weeks BMJ.

The framingham risk score was designed for adults who do not have existing cardiac disease. As one can imagine, predicting risk of mortality in a patient with stable angina is a very different animal. (more…)

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