{"id":15284,"date":"2012-01-12T11:18:44","date_gmt":"2012-01-12T16:18:44","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=15284"},"modified":"2012-01-12T12:36:59","modified_gmt":"2012-01-12T17:36:59","slug":"selections-from-richard-lehmans-weekly-review-week-of-january-9th","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/01\/12\/selections-from-richard-lehmans-weekly-review-week-of-january-9th\/","title":{"rendered":"Selections from Richard Lehman’s Weekly Review: Week of January 9th"},"content":{"rendered":"

\"Richard<\/a>CardioExchange is pleased to be able to reprint selections from Dr. Richard Lehman’s journal review<\/a>: a weekly blog at BMJ.org<\/a> offering commentary on the latest literature.\u00a0 Dr. Lehman is a British general practitioner who started these reviews 14 years ago as\u00a0brief notes\u00a0to encourage further reading\u00a0discussion among friends and colleagues. In his own words, they are still written in a style that tries to provoke and engage the reader while conveying the\u00a0message of the articles from the point of view of a generalist trying to work out what matters for patients.<\/p>\n

Each week, we’ll pull out a couple of his summaries that are relevant to this audience, but we encourage members to engage with the entire blog.<\/p>\n

Week of January 9th<\/strong><\/p>\n

(click here<\/a> to read the full review at the BMJ)<\/p>\n

JAMA\u00a0 4 Jan 2012\u00a0 Vol 307<\/strong><\/p>\n

56\u00a0\u00a0\u00a0 If you look at obesity measured by BMI, and then adjust for insulin resistance, hyperlipidaemia and high blood pressure, weight as such is actually a weak predictor of cardiovascular risk. Which may explain why the absolute benefit of bariatric surgery is not enormous, and is probably non-existent for obese individuals without other risk factors. This is a report from the Swedish Obese Subjects (SOS) study <\/a>at a median of 14.7 years, and it shows a halving of cardiovascular events in the group treated with bariatric surgery. That sounds impressive, but absolute mortality difference actually amounts to 1.3% in favour of surgery. And the benefit was not related to baseline BMI in this study. Even longer term data are needed.<\/p>\n

66\u00a0\u00a0\u00a0\u00a0 I have spent several afternoons over the last few months listening to presentations on readmission rates in US hospitals, wondering all the while how these compare with other health systems. For myocardial infarction, they are very high compared with other developed countries. \u201cHowever,\u201d say the authors<\/a>, \u201cthis difference was greatly attenuated after adjustment for length of stay.\u201d In other words, the facts that the US has the shortest stays for MI, and the highest readmission rates, are not unconnected.<\/p>\n

NEJM\u00a0 5 Jan 2012\u00a0 Vol 366<\/strong>
\n<\/strong><\/p>\n

9\u00a0\u00a0\u00a0\u00a0 A new era in secondary prevention after acute coronary syndrome<\/a> is the headline of one birthday editorial, celebrating the success of low-dose rivaroxaban in reducing a composite end-point of death from cardiovascular causes, myocardial infarction, or stroke in 15,526 patients with recent ACS. And to be fair, this amounted to an actual (small) tally of lives saved: total mortality was reduced from 4.5% to 2.9%. It would take any competitor a comparable amount of effort to show benefit from its own fixed-dose anticoagulant, and two have already tried and failed (apixaban and dabigatran), perhaps because the dosing was wrong. Rivaroxaban also failed at a dose of 5mg b.d., but by halving this it was changed from an agent that caused too many bleeds to one which prevented more events than it caused. Good news for Johnson & Johnson and Bayer shareholders, then: but for post-ACS patients and health systems struggling to contain costs? For these, the \u201cnew era\u201d is a mixed blessing: someone will need to interrogate the individual patient data from this vast 766-centre trial, and then we will have to wait at least a decade for evidence from trials of equal size to find out the optimal anticoagulant\/antiplatelet cocktail for post-ACS patients.<\/p>\n

20\u00a0\u00a0\u00a0 But at least we can cross vorapaxar off the list right away: this new oral protease-activated\u2013receptor 1 (PAR-1) antagonist that inhibits thrombin-induced platelet activation simply caused more bleeds in post-ACS patients<\/a>, without any countervailing benefit. That\u2019s a pity: I rather like the name. (I took a shine to vorapaxar: What a shame we had to axe her).<\/p>\n","protected":false},"excerpt":{"rendered":"

This week’s topics: bariatric surgery, length of stay and MI, secondary prevention after ACS, and vorapaxar<\/p>\n","protected":false},"author":475,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[239,737,655],"class_list":["post-15284","post","type-post","status-publish","format-standard","hentry","category-general","tag-acs","tag-bariatric-surgery","tag-vorapaxar"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/15284","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/475"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=15284"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/15284\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=15284"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=15284"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=15284"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}