Primecuts – This Week In The Journals

July 1, 2013

By Matthew Vorsanger, MD and Brian Greet, MD

Faculty Peer Reviewed

Making health news this week, an ailing Nelson Mandela who has been hospitalized in an intensive care unit for over twenty days was visited by Barack Obama during his trip to South Africa. Considered a “personal hero”, President Obama was robbed of the ability to converse with the prior South African ruler due to the gravity of his illness. California, Nevada and parts of Arizona have been overwhelmed with near record triple digit temperatures resulting in over 170 people needing heat related treatment, as steps to protect the homeless and elderly are underway. Such events further put into perspective the recent morbidity and mortality weekly report from the CDC on June 7th which emphasized the need to protect vulnerable populations. [1] Senator Wendy Davis struggled to remain standing and on topic after ten hours of a planned thirteen hour filibuster hoping to block an abortion bill. Unable to lean on any objects for support, go the bathroom or eat, the efforts from the pink sneaker wearing senator from Texas were successful in aiding to prevent the new Texas abortion restrictions.

As we look back at all the events that transpired this past week, we also are looking ahead. The Look AHEAD research group prospectively randomized type 2 diabetics to intensive lifestyle interventions or to a control arm consisting of diabetic education with the aims to assess differences in cardiovascular outcomes. [2] While patients in the lifestyle intervention arm, which consisted of dietary modification through decreased caloric intake and increased physical activity, had significant reductions in weight and glycated hemoglobin, the results of their primary endpoint were disappointing. During a predefined interim analysis the study was prematurely discontinued after the review committee found, on the basis of a futility analysis, that both arms had similar rates of cardiovascular events despite their interventions.

While intensive lifestyle changes may not reduce the risk of cardiovascular endpoints in diabetics as we would have hoped, at least the combination of clopidogrel and aspirin may reduce the risk of those diabetics with minor strokes to have a subsequent larger cerebrovascular event. Conducted in China the CHANCE research group investigated the occurrence of stroke in patients who received aspirin and clopidogrel twenty four hours after a minor ischemic stroke or transient ischemic attack versus those who received placebo and aspirin. [3] Those randomized to receive aspirin and clopidogrel had an absolute risk reduction of 3.5% (8.2% versus 11.7%) compared to those receiving aspirin alone. Further reassuring outcomes revealed that the risk of hemorrhagic stroke was similar between the two groups (0.3% versus 0.3%) suggesting that dual antiplatelet therapy did not confer an additional bleeding risk.

What’s one of the first things that you do when a patient with acute heart failure is admitted to your service? Perhaps it’s ordering a low-sodium, fluid restricted diet. But is there any evidence to support this? As it turns out, previous studies, although underpowered, have not supported this. A new study this week in JAMA addressed this issue again by randomizing 75 patients admitted with acute decompensated systolic heart failure to a low-sodium, fluid restricted diet (800mg Na and 800cc fluid) versus an unrestricted diet [4]. Flying in the face of conventional wisdom, no differences in weight loss, hospital stay, or 30-day readmission rates were seen between groups. So think twice before you place that diet order!

Aanother study in this week’s issue of JAMA examined the utility of provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia [5]. In 4181 patients who presented to emergency departments with chest pain, non-ischemic EKGs, and negative biomarkers, the utility of stress testing proved to be low. In fact, although 11.2% of patients had positive stress tests, 48.8% of these were false positives on coronary angiography. Only 28 patients overall had findings showing potential benefit from revascularization. In light of these results, a much less aggressive testing approach would likely be appropriate in patients with chest pain without evidence of any other high-risk features.

Other interesting reads this week…

1. Mahaffey KW, et al. Clinical outcomes with rivaroxaban in patients transitioned from vitamin k antagonist therapy: a subgroup analysis of a randomized trial. Ann Intern Med. 2013 Jun 18;158(12):861-8. doi: 10.7326/0003-4819-158-12-201306180-00003.  http://annals.org/article.aspx?articleid=1696643

With the advent of the new oral anticoagulants, questions have been raised not only about their safety in warfarin-naïve patients, but also in patients currently managed on warfarin. Although the ACTIVE W trial suggested a benefit to warfarin over other anticoagulant strategies, this subgroup analysis of the ROCKET-AF trial demonstrates similar safety and efficacy of rivaroxaban in warfarin-naïve vs experienced patients.

2. Stickrath C, et al. Attending rounds in the current era: what is and is not happening.

JAMA Intern Med. 2013 Jun 24;173(12):1084-9. doi: 10.1001/jamainternmed.2013.6041.  http://archinte.jamanetwork.com/article.aspx?articleid=1685887

Attending rounds on inpatient resident services are regarded as one of the cornerstones of house staff education. But what actually happens on them? A cross-sectional study of four teaching hospitals attempted to define this. Discussion of patient care was common (96.7% of the time), while discussion of evidence-based recommendations was rare (7.2%).

3. Guery B, et al. Clinical features and viral diagnosis of two cases of infection with Middle East Respiratory Syndrome coronavirus: a report of nosocomial transmission. Lancet. 2013 May 30. pii: S0140-6736(13)60982-4. doi: 10.1016/S0140-6736(13)60982-4. [Epub ahead of print]  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960982-4/fulltext

More on the novel coronavirus that has been called “a threat to the entire world”. This case series describes two patients who presented with fever, chills, and myalgia progressing to respiratory failure requiring mechanical ventilation and extracorporeal membrane oxygenation.

Dr. Matthew Vorsanger is an Associate Editor, Clinical Correlations 

Dr. Brian Greet is an Associate Editor, Clinical Correlations

Peer reviewed by Neil Shapiro, MD, Editor-In-Chief, Clinical Correlations

Image courtesy of Wikimedia Commons

References:

[1] Heat-Related Deaths After an Extreme Heat Event — Four States, 2012, and United States, 1999–2009. Centers for Disease Control and Prevention. June 7, 2013. (Accessed June 29, 2013, at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6222a1.htm

[2] The Look AHEAD Research Group. Cardiovascular Effects of Intensive Lifestyle Intervention in Type 2 Diabetes. N Engl J Med. 2013 Jun 24. [Epub ahead of print] PubMed PMID: 23796131.

[3] Wang Y, et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. N Engl J Med. 2013 Jun 26. [Epub ahead of print] PubMed PMID: 23803136.

[4] Aliti GB, et al. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013 Jun 24;173(12):1058-64. doi: 10.1001/jamainternmed.2013.552. http://archinte.jamanetwork.com/article.aspx?articleid=1689981

[5] Hermann LK, et al. Yield of routine provocative cardiac testing among patients in an emergency department-based chest pain unit. JAMA Intern Med. 2013 Jun 24;173(12):1128-33. doi:  10.1001/jamainternmed.2013.850.  http://archinte.jamanetwork.com/article.aspx?articleid=1690009

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