{"id":43972,"date":"2014-07-07T16:49:16","date_gmt":"2014-07-07T20:49:16","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=43972"},"modified":"2014-07-07T16:50:32","modified_gmt":"2014-07-07T20:50:32","slug":"selections-from-richard-lehmans-literature-review-july-7th","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2014\/07\/07\/selections-from-richard-lehmans-literature-review-july-7th\/","title":{"rendered":"Selections from Richard Lehman\u2019s Literature Review: July 7th"},"content":{"rendered":"

CardioExchange is pleased to reprint this selection from Dr. Richard Lehman\u2019s\u00a0weekly journal review blog<\/a>\u00a0at\u00a0BMJ.com<\/a>. Selected summaries are relevant to our audience, but we encourage members to engage with the\u00a0entire blog<\/a>.<\/em><\/p>\n

NEJM<\/em> 3 July 2014 Vol 371<\/strong><\/p>\n

Loss-of-Function Mutations in APOC3 and Ischemic Vascular Disease, Triglycerides, and Coronary Disease (pg. 22, 32):<\/strong> My heart sank last week when two papers appeared on the NEJM<\/em> website with the titles Loss-of-Function Mutations in APOC3<\/em>, Triglycerides, and Coronary Disease<\/a>, and Loss-of-Function Mutations in APOC3<\/em> and Risk of Ischemic Vascular Disease<\/a>. I resolved to ignore them. However, Harlan Krumholz \u2018s comments on them<\/a>\u00a0really have to be read: \u201cThis research\u201d, he said, \u201chas absolutely no implications for clinical practice. It might one day be seen as a pivotal study that led to the development of remarkable drugs, but that is far away. I hope people don\u2019t read it and think that it has relevance to their current decisions about treatment.\u201d<\/p>\n

JAMA Intern Med<\/em> July 2014<\/strong><\/p>\n

Effect of Patients\u2019 Risks and Preferences on Health Gains With Plasma Glucose Level Lowering in Type 2 Diabetes Mellitus:<\/strong> Four years ago, John Yudkin drew my attention to a study that had just appeared in the Archives of Internal Medicine<\/em><\/a>,\u00a0illustrating a new and radically patient centred kind of modelling for \u201cutility versus disultility\u201d in long term treatment. It appeared under the banner of \u201cLESS IS MORE\u201d and bore the title: \u201cVariation in the Net Benefit of Aggressive Cardiovascular Risk Factor Control Across the US Population of Patients With Diabetes Mellitus.\u201d It should have shaken the world but, as so often in this field, it was politely ignored because it ran counter to the standard model of practice. John had heard that the Michigan authors had another paper up their sleeve, dealing with the individual utilities or disutilities of varying degrees of glucose control in the same population. We grew so eager to see this published, that John went over to recruit Harlan K at Yale to join forces in urging Rod Hayward to complete work on it. I joined the trip and my life was changed, but the study has only now been published<\/a>.<\/p>\n

Everybody should read it. \u201cTreating patients with HbA1c levels less than 9% should be individualized on the basis of estimates of benefit weighed against the patient\u2019s views of the burdens of treatment.\u201d Do you dare to have this discussion with your patients with longstanding type 2 diabetes mellitus? Or with any other patient you have \u201cput on\u201d long term treatment? \u201cWe estimate that the expected gain in QALYs for a 1-point change in HbA1c level in a 75-year-old is 0.06 years (22 days), even with the favorable assumption that glycemic control\u2019s cardiovascular benefit extends to the elderly.\u201d Now go back to their original paper and think hypertension.<\/p>\n

The BMJ<\/em> 5 July 2014 Vol 349<\/strong><\/p>\n

Revascularization vs. Medical Treatment in Patients with Stable CAD:<\/strong> Network meta-analyses are a mixed blessing. Experts argue that by using a bayesian random effects Poisson regression model, you can preserve randomised treatment comparisons within trials. But that begs the question of how you can achieve dependable comparisons between trials, robust enough to guide clinical practice. Unfortunately I was born with loss of function variants on my STATS-WONK<\/em> alleles and cannot work that out. This network meta-analysis<\/a> would have us believe that the era of COURAGE has come to an end: thanks to better drug eluting stents and techniques for coronary artery bypass surgery, people with stable coronary artery disease will now experience fewer deaths and myocardial infarctions if they have early invasive treatment. But I couldn\u2019t dig out the figures that\u00a0would allow me to share any decisions confidently with actual patients. I fear that this meta-analysis, which is very hard to confirm or contest, will simply be used as a pretext for interventionists to return en masse to their bad old habits.<\/p>\n

 <\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

This week’s topics include the effect of patients\u2019 risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes, a meta-analysis of revascularization vs. medical treatment in patients with stable CAD, and more.<\/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":[2298,1747,2299,2301,481,2300,827,940,807,469],"class_list":["post-43972","post","type-post","status-publish","format-standard","hentry","category-general","tag-apoc3","tag-coronary-disease","tag-ischemic-vascular-disease","tag-medical-treatment","tag-mutations","tag-plasma-glucose-level-lowering","tag-revascularization","tag-stable-cad","tag-triglycerides","tag-type-2-diabetes"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/43972","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=43972"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/43972\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=43972"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=43972"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=43972"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}