{"id":46522,"date":"2015-01-12T17:22:45","date_gmt":"2015-01-12T22:22:45","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=46522"},"modified":"2015-01-12T17:22:45","modified_gmt":"2015-01-12T22:22:45","slug":"selections-from-richard-lehmans-literature-review-january-12th","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2015\/01\/12\/selections-from-richard-lehmans-literature-review-january-12th\/","title":{"rendered":"Selections from Richard Lehman\u2019s Literature Review: January 12th"},"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

Ann Intern Med<\/em> 6 Jan 2015 Vol 162<\/strong><\/p>\n

D-dimer Testing to Select Patients With a First Unprovoked Venous Thromboembolism Who Can Stop Anticoagulant Therapy (pg. 27):<\/strong> Having an unprovoked deep vein thrombosis is a powerful risk factor for having a second DVT. The risk declines over time but never quite goes away. Researchers in Canada<\/a> sought to establish whether it would be useful to measure D-dimer before stopping anticoagulation, and then, if the D-dimer was negative, stop the anticoagulants, measure it again after a month and restart the drugs if it had become positive. Or leave them off if both tests were negative. It didn\u2019t quite work in men, who showed a 9.7% annual recurrence rate even after two negative tests. In women the rate was 5.4%, which might just be acceptable.<\/p>\n

Effects of Blood Pressure Reduction in Mild Hypertension (OL):<\/strong> Are you the kind of clinician who actually treats blood pressure? If you\u2019re a GP, that means you\u2019re probably responsible for about 400 people taking drugs for let\u2019s say an average of 15 years = 52 million drug-hours. So do click on the link<\/a>\u00a0and take half an hour of your own time to mull over this free systematic review of the effects of BP reduction in mild hypertension<\/a>. Consider what you are trying to do. Reduce cardiovascular risk, right? If you have come across John Yudkin\u2019s Ten Commandments, you will remember the one that says \u201cThou shalt treat according to level of risk and not to level of risk factor.\u201d So for each \u201cpatient\u201d on BP-lowering medication, you have calculated a risk score such as QRISK? And discussed each element of it with each individual and what non-drug and drug treatments might help to reduce it? Giving every person an individualized number-needed-to-treat and number needed-to-harm for each intervention? If you have answered yes to all of these questions, you must be lying, because the information to support this detail of shared decision making simply isn\u2019t there. This review<\/a>, which lumps together all sorts of individuals\u2014with and without diabetes, some with previous treatment and some not\u2014ends up concluding that treating people with \u201cgrade 1 hypertension\u201d is probably going to reduce cardiovascular events but that the confidence intervals are huge. So which risk-reducing intervention is it going to be? More physical activity? A statin? A BP lowering agent? A more \u201cMediterranean\u201d diet? Metformin? All of the above, or none of them? After all, it is the symptomless individual who has to decide on the basis of the information you give them. This is the mess we are in and the mess we need to get out of if shared decision making about risk reduction is going to become a reality. Because \u201cmild hypertension\u201d is not a thing in itself: it is just a single risk factor. And \u201call-cause mortality\u201d\u2014the thing that gets us all in the end\u2014does not seem to be postponed by any of the mild BP treatments described in this paper.<\/p>\n

JAMA Intern Med<\/em> Jan 2015<\/strong><\/p>\n

Association Between Dietary Whole Grain Intake and Risk of Mortality:<\/strong> Perhaps the grim reaper can be held off a while by eating more whole grain products. This is one possible conclusion to be drawn from dietary information<\/a> fed into those two familiar American cohort studies, 74\u2009341 women from the Nurses\u2019 Health Study (1984\u20132010) and 43\u2009744 men from the Health Professionals Follow-Up Study (1986\u20132010). \u201d These data indicate that higher whole grain consumption is associated with lower total and CVD mortality in US men and women, independent of other dietary and lifestyle factors.\u201d So the genes that make people like to eat grainy things may be associated with the genes that make people die less from cardiovascular disease. Or maybe the grainy things themselves have that effect. Either way, I shall eat what I like, avoiding buckwheat and couscous and similar vile things.<\/strong>
\n<\/strong>
\nLancet<\/em> 10 Jan 2015 Vol 385<\/strong><\/p>\n

Efficacy and Safety of LDL-Lowering Therapy Among Men and Women (OL):<\/strong> The Cholesterol Treatment Trialists\u2019 Collaboration offer a paper on \u201cEfficacy and safety of LDL-lowering therapy among men and women: meta-analysis of individual data from 174\u2008000 participants in 27 randomised trials.<\/a>\u201d But although there is now some weak evidence LDL-C lowering with ezetimibe may improve cardiovascular outcomes, all the evidence in this review is about statins. These drugs certainly lower LDL-C and \u201cThese results indicate that, for each 1 mmol\/L reduction in LDL cholesterol, statin therapy reduced major vascular events by about a fifth, major coronary events by a quarter, coronary revascularisations by a quarter, and ischaemic stroke by just under a fifth, and that these proportional reductions were similar in men and women, even though on average women had somewhat lower absolute cardiovascular risk in these trials.\u201d But it\u2019s not just pedantic obstinacy that makes me chary about putting all this down to LDL-C lowering. I\u2019m worried that people will therefore carry on treating cholesterol as some kind of target independent from total cardiovascular risk, whereas we need always to obey the commandment \u201cTreat to level of risk and not to level of risk factor.\u201d And scientifically I still can\u2019t understand how statins can produce marked improvements in acute events before they have had time to reduce HDL-C.<\/p>\n

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

This week’s topics include the effects of BP reduction in mild hypertension, the association between dietary whole grain intake and risk of mortality, 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":[492,499,1538,2466,1846,747,2465],"class_list":["post-46522","post","type-post","status-publish","format-standard","hentry","category-general","tag-anticoagulation","tag-blood-pressure-monitoring","tag-d-dimer-test","tag-ldl-lowering-therapy","tag-mild-hypertension","tag-venous-thromboembolism","tag-whole-grains"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/46522","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=46522"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/46522\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=46522"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=46522"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=46522"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}