Med consults rejoice! The long awaited updated guidelines for perioperative cardiac evaluation and management for non-cardiac surgery were published in last month’s edition of Circulation. There are several key changes in both the approach to pre-operative cardiac evaluation and peri-operative cardiac medication management. Among these changes is the recognition that non-invasive testing for coronary artery disease is unlikely to change management, and is therefore no longer recommended in several situations for which testing was previously considered. These include patients going for low-risk surgeries regardless of risk factors, and patients going for intermediate or high-risk surgeries with good functional capacities regardless of risk factors. This less-is-more mantra also seems to apply to the use of perioperative beta-blockade. Favorable recommendations for peri-operative beta-blocker therapy are only given to those with known coronary artery disease or at high cardiac risk for intermediate risk or vascular procedures. Though the evidence is limited, there is a strong recommendation for patients already taking beta-blockers to continue to do so during the perioperative period. Finally, the guidelines seemed to align themselves with the current thinking on peri-operative statin use. Patients on statins should continue their use during the peri-op period and patients going for vascular surgery, and initiation of statin therapy should be considered for those going for intermediate procedures with multiple cardiac risk factors.
While we may no longer need to obtain a stress test for our veterans going for cataract surgery, new evidence suggests we need to be more vigilant about screening those returning from combat for mental health disorders. A study in last week’s JAMA compared results from surveys done among ~88,000 Army veterans immediately upon return from Iraq with similar surveys done a median of 6 months later. The primary outcomes studied included rates of positive screens for PTSD, major depression, alcohol disorders, or other mental health disorders, as well as rates of referral and use of mental health services. Significant increases in rates of several mental health concerns were noted in the later survey including increased rates of positive depression screenings, PTSD positive screens, and increased concerns about interpersonal conflict. Appropriately, this led to significantly more referrals for mental health services after the second screen. These differences were larger between National Guard and Reservists returning from duty compared to active duty veterans, potentially due to the stress of returning to work and differences in healthcare benefits. The results clearly demonstrate that initial screening upon return from Iraq fails to identify many veterans at risk for mental health disorders and we owe it to our returning veterans to screen them longitudinally for mental health disorders.
On to a discussion of a less polarizing battle, the biologic war continues in the fight against cancer. An open-label, randomized trial in the November 15th issue of NEJM compared the effect of Cetuximab, a monoclonal antibody targeted to the epidermal growth factor receptor (EGFR), with best supportive care on patients with advanced colon cancer with EGFR expression who had failed or for whom standard chemotherapy regimens were contraindicated. The primary endpoint studied was overall survival. Median survival was longer in the Cetuximab treated patients (6.1 months vs. 4.6 months) and overall survival was significantly improved with Cetuximab treatment (HR for death, 0.77, CI 0.64-0.92, p=0.005). Overall, adverse events were more frequent in the Cetuximab treated group and this was driven by significant differences in the frequency of rash, non-neutropenic infections, and pain. However Cetuximab treatment was also associated with significant improvements in quality of life.
Ever wonder how rheumatologists determine which medications to start on your rheumatoid arthritis patients? An early release online systematic review in the Annals of Internal Medicine attempts to answer that question. They analyzed randomized trials and cohort trials with the goal of comparing the effectiveness and harms of most of the commonly used DMARDs for RA. While head-to-head evidence comparing different agents was limited, no one agent, biologic or synthetic, was superior to another as a monotherapy. Evidence did support the use of combination therapy, in particular methotrexate with the addition of a biologic agent for those who did not respond sufficiently to a single drug. The data was insufficient to identify and discrepancies in the number or type of adverse effects among the different agents.