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.

JAMA  24-31 Oct 2012  Vol 308

Conventional CV Risk Factors and Risk of Peripheral Artery Disease in Men (pg. 1660): Medicine is full of surprises, but sometimes things are just the way you thought they were. Back in 1973, I was taught that the causes of peripheral arterial disease in men were smoking, diabetes, hypertension and high cholesterol. Then in 1986, the Health Professionals Follow-up Study recruited 44 985 men without known cardiovascular disease and followed them up for 25 years to discover the causes of peripheral arterial disease. This week you can discover that they are: smoking, diabetes, hypertension and high cholesterol.

NEJM  25 Oct 2012  Vol 367

Radiofrequency Ablation as Initial Therapy in Paroxysmal AF (pg. 1587): Even the New England Journal is not an entirely dross-free zone, but a number of papers in this week’s issue show why every doctor should try to read it regularly. We’ve all wished that atrial fibrillation could be abolished, and indeed this week’s Lancet makes the broad and not quite intelligible claim that “new technologies have propelled arrhythmology into an effective modern therapeutic arena.” Here an important trial tests the truth of this claim in relation to one such new technology — Radiofrequency Ablation as Initial Therapy in Paroxysmal Atrial Fibrillation. The Danish Heart Foundation and others paid for a direct comparison trial of primary pathway ablation versus standard drug therapy in 294 patients with newly presenting AF. There were more major complications in the ablation group and overall at 24 months there was no significant difference in the overall burden of AF between groups.

Lancet  27 Oct 2012  Vol 380

Duration of CPR and Survival After In-Hospital Cardiac Arrest (pg. 1473): A large American observational study looks at outcome differences between hospitals with different duration times for cardiopulmonary resuscitation. The hospitals where CPR is recorded as lasting longest tend to have slightly higher CPR survival rates. The moral seems to be: don’t give up before 25 minutes.

Everolimus-Eluting Stent vs. Bare-Metal Stent in STEMI (pg. 1482): Hard on the heels of last week’s episode of Stent Wars, here comes another: Everolimus-eluting stent versus bare-metal stent in ST-segment elevation myocardial infarction (EXAMINATION): 1 year results of a randomised controlled trial. The trial had a “patient-oriented combined endpoint” of all-cause death, any recurrent myocardial infarction, and any revascularisation at 1 year. On that basis it was a draw.

Job Strain and CHD (pg. 1491): “If he doesn’t ease up, he’ll have a heart attack.” How true is it that job strain is a risk factor for coronary heart disease? Slightly true, according to a massive survey of 13 European observational studies in which a total of nearly 200,000 participants were asked about stress in the workplace. The authors conclude that the effect size is very small in comparison with conventional coronary risk factors.

Safe Exclusion of Pulmonary Embolism Using the Wells Rule and Qualitative D-Dimer Testing: A Dutch prospective cohort study of how to exclude pulmonary embolism in primary care reaches a much more robust conclusion. “A Wells score of ≤4 combined with a negative qualitative D-dimer test result can safely and efficiently exclude pulmonary embolism in primary care.” The so-called “qualitative” D-dimer test was a new point-of-care test which was not interpretable in 6% of patients with suspected PE. This is much better than previous tests I have tried to use, and is probably as good as one can get. So this is a definite move forward, consistent with many other studies of VTE in primary care.

Arch Intern Med  22 Oct 2012  Vol 172

Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for GI Bleeding: Your patient is taking warfarin and has a gastrointestinal bleed, so you stop the warfarin. How long for? Probably the best answer is for as short a time as possible, since for most patients the risk of a thrombotic event (and death) is greater than that of a further GI bleed.