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Ischaemic heart disease

Clopidogrel should be given for one year after stenting ▸

Most cardiologists presently prescribe 2–4 weeks of clopidogrel after placing coronary stents. In patients with acute coronary syndromes, the CURE study suggests benefit to nine months, although most of the benefit was achieved in the first three days. The CREDO study suggests that one year of therapy may be appropriate. At one year, long term clopidogrel treatment was associated with a 26.9% relative reduction in the combined risk of death, myocardial infarction (MI), or stroke (95% confidence interval (CI) 3.9% to 44.4%; p =0.02; absolute reduction 3%). Clopidogrel pretreatment did not significantly reduce the combined risk of death, MI, or urgent target vessel revascularisation at 28 days (reduction 18.5%, 95% CI −14.2% to 41.8%; p = 0.23). However, in a prespecified subgroup analysis, patients who received clopidogrel at least six hours before percutaneous coronary intervention (PCI) experienced a relative risk reduction of 38.6% (95% CI −1.6% to 62.9%; p = 0.051) for this end point compared with no reduction with treatment less than six hours before PCI. Risk of major bleeding at one year increased, but not significantly (8.8% with clopidogrel v 6.7% with placebo; p = 0.07).

Cardioselective β blockers can be safely used in patients with asthma/COPD ▸

Randomised, blinded, placebo controlled trials that studied the effects of cardioselective β blockers on forced expiratory volume in one second (FEV1), symptoms, and the use of inhaled β2 agonists in patients with reactive airway disease were selected for meta-analysis. Nineteen studies on single dose treatment and 10 studies on continued treatment were included. Administration of a single dose of a cardioselective β blocker was associated with a 7.46% (95% CI 5.59% to 9.32%) decrease in FEV1 and a 4.63% (95% CI 2.47% to 6.78%) increase in FEV1 response to β agonist compared with placebo, with no increase in symptoms. Trials lasting from three days to four weeks produced no significant change in FEV1 (−0.42%, 95% CI −3.74% to 2.91%), symptoms, or inhaler use compared with placebo but maintained an 8.74% (95% CI 1.96% to 15.52%) increase in β agonist response. No significant treatment effect in terms of FEV1 was found in patients with concomitant chronic obstructive pulmonary disease, whether single doses (change in FEV1 −5.28%, 95% CI −10.03% to −0.54%) or continued treatment (change in FEV1 1.07%, 95% CI −3.3% to 5.44%) was given.

Off-pump CABG reduces neurocognitive injury ▸

Sixty patients undergoing coronary artery bypass graft surgery for triple vessel disease were prospectively randomised to the off-pump or on-pump technique. The incidence of neurocognitive impairment at one week postoperatively was 27% (8 of 30) in the off-pump group and 63% (19 of 30) in the on-pump group (p = 0.004); and at 10 weeks postoperatively was 10% (3 of 30) in the off-pump group and 40% (12 of 30) in the on-pump group (p = 0.017). This is in keeping with previous data suggesting that the platelet and leucocyte activation set off by the bypass machine circuit is deleterious to the brain.

GUSTO-V still negative at one year ▸

Half dose reteplase and use of abciximab (a glycoprotein IIb/IIIa receptor blocker) should have improved artery patency and outcome after ST elevation MI compared to reteplase alone. In 16 588 patients, however, all cause mortality was 8.38% in both the reteplase group and the dual therapy group. There were fewer reinfarctions in the first seven days, but this did not translate into an overall mortality advantage. The reason may be that vessel patency was not improved enough by dual therapy to affect mortality. Primary angioplasty, with 95% vessel patency rates, does appear to be significantly better than either, unless pre-hospital thrombolysis is being considered.

Elderly patients PROSPER with pravastatin ▸

Baseline cholesterol concentrations ranged from 4.0 mmol/l to 9.0 mmol/l in 5804 patients aged 70–82 years. Pravastatin 40 mg/day decreased low density lipoprotein cholesterol concentrations by 34% and reduced the incidence of the primary end point (coronary death/non-fatal MI/stroke) to 408 events compared with 473 on placebo (hazard ratio 0.85, 95% CI 0.74 to 0.97; p = 0.014) at a mean follow up of 3.2 years. Stroke rates were not reduced, perhaps because the duration of follow up was three and not five years as in previous trials.

CRP to identify risk in young women: ▸

In a subgroup of the RATIO (risk of arterial thrombosis in relation to oral contraceptives) study based in the Netherlands women with peripheral arterial disease (PAD) were identified. All traditional risk factors were more common in women with PAD as were more common infections (except Epstein-Barr). Specifically, the odds ratio for women with PAD and previous shingles, mumps, pneumonia, chronic bronchitis, peptic ulcer, periodontitis, and gingivitis was between 1.5 (for mumps) and 4.6 for peptic ulcer. Risk of PAD increased with the cumulative number of infections. Women with PAD and a C reactive protein (CRP) in the higher two quartiles (1.4–5.0 and > 5.1) had an odds ratio of 5.4 and 5.3 when adjusted for age, sex, and education, and 3.9 and 3.1 when multiply adjusted.

Heart failure

Digoxin has no role in treating women with heart failure ▸

Among the 6800 patients in the digitalis investigation group study, there was an absolute difference of 5.8% (95% CI 0.5% to 11.1%) between men and women in the effect of digoxin on the rate of death from any cause (p = 0.034 for the interaction). In the multivariable analysis, digoxin was associated with a significantly higher risk of death among women (adjusted hazard ratio for the comparison with placebo 1.23, 95% CI 1.02 to 1.47), but it had no significant effect among men (adjusted hazard ratio 0.93, 95% CI 0.85 to 1.02; p = 0.014 for the interaction).

Treatment of heart failure has a long way to go ▸

In 11 000 patients with heart failure, only 50% of echocardiograms showed systolic left ventricular dysfunction. Only 60% of their patients were on angiotensin converting enzyme (ACE) inhibitors, 34% on β blockers, and 20% on both. The doses used were 50% of the targets set by the European Society of Cardiology.

Hypertension

ACE inhibitors should become first line antihypertensive agents in renal impairment ▸

Over 1000 African Americans with renal impairment related to hypertension were randomised to either severe (blood pressure 128/78 mm Hg) or moderate blood pressure control (mean 141/85 mm Hg). In addition, they were randomised to one of three antihypertensive drugs. There was no difference in the decline in glomerular filtration rate between the two groups. Nor was there any difference in the clinical end point of decline in glomerular filtration rate by 50%/death/end stage renal disease. However, compared with the metoprolol and amlodipine groups, the ramipril group manifested risk reductions in the clinical composite outcome of 22% (95% CI 1% to 38%; p = 0.04) and 38% (95% CI 14% to 56%; p = 0.004), respectively. There was no significant difference in the clinical composite outcome between the amlodipine and metoprolol groups.

General cardiology

Use of frusemide drive in renal failure has no scientific basis ▸

It has been clear for some time that dopamine infusions, although often used in acute renal failure to encourage renal recovery, have no evidence of benefit. The same seems to be true for frusemide (furosemide) drive. A total of 552 patients with acute renal failure were audited. In 59%, diuretics were used at the time of nephrology consultation. These patients were older, and sicker. However, adjusting for this, diuretic use was associated with a significant increase in the risk of death or non-recovery of renal function (odds ratio (OR) 1.77, 95% CI 1.14 to 2.76). The risk was magnified (OR 3.12, 95% CI 1.73 to 5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to diuretics.

Screening for AAA is cost effective ▸

Ultrasound screening of men aged 65–74 years found 1333 aneurysms in 27 147 people (4.9%). A matched group were followed without screening. Men with abdominal aortic aneurysms (AAA) > 3 cm were reviewed at one year, those 3.0–5.5 cm diameter were seen at three months, and those > 5.5 cm or expanding > 1 cm per year were offered surgery. There were 65 aneurysm related deaths (absolute risk 0.19%) in the screening group, and 113 (0.33%) in the control group (risk reduction 42%, 95% CI 22% to 58%; p = 0.0002), with a 53% reduction (95% CI 30% to 64%) in those who attended screening. Thirty day mortality was 6% (24 of 414) after elective surgery for an aneurysm, and 37% (30 of 81) after emergency surgery. Cost effectiveness was shown for screening, with cost per life year saved being < £30 000.

Syncope as a presenting feature of aortic dissection ▸

The International Registry of Acute Aortic Dissection (IRAD) collects data from more than six countries. Of 728 patients with acute aortic dissection, 13% report syncope. This may be caused by tamponade, carotid involvement, or spinal artery occlusion. It may also be a reaction to pain, or an aortic baroreceptor reflex. Most worrying is that 3% of dissections presented with syncope alone, without chest or back pain. This raises the question of how hard dissection should be sought in patients presenting with syncope and no other symptoms.

Mercury is bad for the brain, but what about the heart? ▸

Mercury accumulates in oily fish, and is found in high concentrations in swordfish. Pregnant women and children in the USA are advised to avoid too much oily fish. Two studies in the New England Journal of Medicine come to opposite conclusions about the cardiac effects. The beneficial effects of fish oils on the heart may be reduced by low level poisoning according to Guallar et al. This effect was not found in another study by Yoshizawa et al.

Journals scanned

American Journal of Medicine; American Journal of Physiology: Heart and Circulatory Physiology; Annals of Emergency Medicine; Annals of Thoracic Surgery; Archives of Internal Medicine; BMJ; Chest; European Journal of Cardiothoracic Surgery; Lancet; JAMA; Journal of Clinical Investigation; Journal of Diabetes and its Complications; Journal of Immunology; Journal of Thoracic and Cardiovascular Surgery; Nature Medicine; New England Journal of Medicine; Pharmacoeconomics; Thorax

Reviewers

Dr Oliver Segal, Dr Tom Wong, Dr Vias Markides, Dr Diana Gorog, Dr Akhil Kapur, Dr Andrew Sharp, Dr Pipin Ko

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