ShortCuts- This Week in the Journals

November 4, 2008

vote.jpgCommentary by Elizabeth Sedlis, MD PGY-2

Reviewed by Judith Brenner, MD, Associate Editor, Clinical Correlations

This past week was filled with heart racing mid-fall traditions which brought New Yorkers out to the streets in droves.  Last Friday was the 35th annual village Halloween parade attended by 2 million nighttime revelers, and Sunday was the 38th annual New York City Marathon with 39,000 runners pounding the pavements of our five boroughs.  Congratulations to all those inspirational athletes.  This coming week is guaranteed to make your heart race with Election Day finally taking place today… this will be the last shortcuts with a plug to go out and vote!

Incidentally, heart racing was the topic of a couple of papers in this week’s journals… 

Beta blockers for hypertension: the end of an era? 

The mortality benefits of beta-blockers in patients with MI and heart failure have been known for years, but the benefits of beta-blockers used for the treatment of hypertension have been questioned.  An article and its accompanying editorial in last week’s issue of Journal of the American College of Cardiology added yet another nail to the coffin.  Bangalore et al published a meta-analysis which included 22 RCTs that included beta blockers.  This systematic review included over 30,000 on beta blockers vs 30,000 on other anti-hypertensives and a small number on placebo.  As heart rate predictably declined, use of beta blockers was associated with worse outcomes in the the following areas: all-cause mortality (r = -0.51 p<0.0001), CV mortality (r = -0.61 p<0.0001), and incidence of MI (r = -0.85 p<0.0001), stroke (r = -0.20 p+0.06), and heart failure (r = -0.64 p<0001).  One of the main critiques of the meta-analysis is that the authors do not have full access to the databases of the original studies.

Having said this, perhaps even more interesting than the article itself is the accompanying editorial written by Dr. Norman Kaplan of UT Southwestern.  In “Beta-Blockers in Hypertension: Adding Insult to Injury,” he describes many years worth of trial data that have significantly affected British hypertension guidelines such that, in its latest iteration in 2006, “beta-blockers are no longer preferred as a routine initial therapy for hypertension.” 

Whether this large meta-analysis actually leads to a change in practice in the US is questionable, although it certainly should make us all pause for a moment and certainly begs for further studies comparing the safety of different beta-blockers in hypertension. 

PE: Simplifying the diagnosis?

The diagnosing of pulmonary embolism has plagued clinicians for decades.  Many algorithms have been developed to improve accuracy of the diagnosis, but we still struggle because the implications of diagnosis or misdiagnosis are grave.  In 2006 a standardized clinical decision rule, known as the Revised Geneva Score, which was independent of a clinician’s judgment, was developed and validated.  The score included 8 risk factors, including:

  • age >65

  • previous deep vein thrombosis or PE

  • recent surgery or lower-limb fracture

  • active malignancy

  • unilateral lower limb pain

  • hemoptysis

  • heart rate >75 beats/minute

  • unilateral edema and pain on lower-limb deep venous palpation.

These risk factors were assigned different weights, and the score led to an acceptable risk stratification of the patients into low, intermediate, and high risk.  However, having differing weights to the risk factors may lead to miscalculations in an acute setting.  In this week’s Archives of Internal Medicine, Klok et al reevaluated data from 2 large trials that included over 1000 patients using a simplified version of the Geneva Score, the so-called ‘Revised Geneva Score’.   Instead of the weighted score, they assigned 1 point for each risk factor and found that the diagnostic accuracy didn not differ from that of the weighted score if combined with a normal D-dimer using a high sensitivity assay.  It also did not differ from other prediction rules used in the diagnosis of PE, including among others, the Wells rule.  Furthermore, during 3 months of follow-up, no patient with a normal D-dimer and a low or intermediate clinical probability or a “PE unlikely” assessment was diagnosed with venous thromboembolism.  This diagnostic accuracy and clinical utility of the simplified score should be confirmed in a prospective study. 

Will we ever say “a statin a day…”?

So, with all the parading and running around the city, many New Yorkers reached for anti-inflammatory agents to help soothe their aching joints, but as the following studies showed, maybe they should be reaching for their statins as well…

The effects of statins beyond cholesterol lowering are wide ranging, and this week two common yet very different clinical scenarios, prostate cancer detection and community acquired pneumonia, were considered to be affected by statin use.  The effects on PSA were studied longitudinally in over 1000 men for 16 years at the Durham Veterans Affairs Medical Center.   PSA levels significantly declined after initiation of statin treatment.  For every 10% decrease in LDL after initiation of a statin, there was a 1.64 decrease in PSA.  The concern is that this could confuse some men who are potentially candidates for prostate biopsy (ie those with pre-statin PSA >2.5) if their post-statin PSA declines into a “safe” zone. 

Whether this decline in PSA associated with statin use is of any clinical significance (protective of cancer or complicating the detection of cancer) is yet to be determined and further studies are needed.

There was also news about a possible role of statins in the treatment of pneumonia. In November’s issue of the American Journal of Medicine, Chalmers et al report on a prospective observational study that although patients who were prescribed a statin had a more severe pneumonia, their development of complicated pneumonia and their 30-day mortality was significantly lower than those not prescribed a statin.  More food for thought and perhaps some day, we will be saying “a statin a day keeps the doctor away.” 

And to our good old favorite, the New York Times.  This week the New York Times reported on research conducted at Cooper University Hospital in Camden, NJ regarding inflammatory effects of blood transfusions.  The FDA allows blood to be stored up to 42 days prior to use, but this study presented at the American College of Chest Physicians suggests that patients receiving blood more than 29 days old are at increased risk of infections such as bacteremia, sepsis, pneumonia, and urinary tract infections, possibly from cytokine release in the degrading blood.  Although no shift in policy has been suggested, this finding should be looked into further and perhaps discussed with patients when they consent for blood products. 

Lastly, I want to end this piece with a sobering reminder for doctors.  This is a week of excitement and good distraction: Halloween, the Marathon, and, Election Day.  As the excitement passes and days get shorter and shorter, many will find themselves never seeing daylight.  As physicians, it is important to remember to continue taking care of ourselves.  The New York Times this week published a piece reminding us to be aware of the dangers of burnout, specifically in medical students.  Dr. Chen writes a commentary on a study of burnout in a population of 2,248 medical students from 7 medical schools across the country which found that nearly half the students met the criteria for burnout (emotional exhaustion, depersonalization, and low sense of personal accomplishment) and 11% of the students had suicidal thoughts in the past year.  Furthermore, the burnout is associated with a drop in levels of empathy toward patients.  Although the results are “incredibly disconcerting,” they are real and medical schools are designing interventions to help improve student wellness.  We need to take care of ourselves in order to take care of our patients.

References:

1. Sripal Bangalore, MD, MHA, Sabrina Sawhney, MD and Franz H. Messerli, MD. Relation of Beta-Blocker-Induced Heart Rate Lowering and Cardioprotection in Hypertension.  J Am Coll Cardiol, 2008; 52:1482-1489

2. Klok et al., Simplification of the Revised Geneva Score for Assessing Clinical Probability of Pulmonary Embolism. Arch Intern Med. 2008;168(19):2131-2136.

3. Hamilton et al., The Influence of Statin Medications on Prostate-specific Antigen Levels.  J. Natl. Cancer Inst..2008

4. Chalmers et al., Prior Statin Use Is Associated with Improved Outcomes in Community-acquired Pneumonia. The American Journal of Medicine 2008; 121 (11): 1002-1007

NYTimes

5. Study Links Age of Blood in Transfusions to Infections – October 29th, 2008

6. Medical Student Burnout and the Challenge to Patient Care – October 30th, 2008

 

 

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