ShortCuts- This Week in the Journals

October 21, 2008

120px-fall-tree.jpgCommentary by Sabina Berezovskaya MD, PGY-3.  Reviewed by Danise Schiliro- Chuang MD.

Hello and welcome to another addition of shortcuts. Hoping the autumn foliage and beautiful weekend weather have refreshed you and your week is starting off well. Here are a few of the latest studies making headlines that you should know about. Read on!

Should We Bypass Banding?

As rates of obesity (BMI >40 kg/m2) have skyrocketed over the past few decades, patients and physicians alike are searching for the cure of this 21st century epidemic. From diets to pills, none have offered an effective and lasting solution. This brings us to the increasingly popular “last resort” measure, bariatric surgery.  Thus far two procedures have dominated the realm of surgical weight loss: laparoscopic adjustable gastric banding and roux-en-Y gastric bypass. Laparoscopic banding has been touted as the safe and reversible fix, whereas bypass still remains the standard of care. At the present time limited data is available comparing these competing procedures. To address this issue the American Journal of Medicine presented an article titled “Banding or bypass? A systematic review comparing the two most popular bariatric procedures.”  Roux-en-Y gastric bypass came out as a clear winner in terms of weight loss and resolution of co morbidities (i.e. diabetes, obstructive sleep apnea). It was estimated that there was a 26 % greater loss of excess body weight with bypass procedures than with banding. One explanation proposed for the observed difference was that surgical bypassing of the distal stomach, duodenum and proximal jejunum may actually alter secretion of hormones that influence sensation of satiety, hunger and glycemic control. Additionally, higher rates of re-operation and long term complications, such as port problems, band slippage, band erosion, hernias, and gallbladder problems were reported in the banding arm.  It should be noted, however, that the few complications associated with bypass were of greater morbidity (i.e. obstruction, anastomotic leak); in addition, comparison of operating room time, length of hospitalization, and rates of perioperative complications favored banding. For these reasons, banding has recently come into vogue among surgeons and patients. So what should we be recommending? Until further high quality studies are available, the authors strongly support Roux-en -Y gastric bypass as the procedure of choice. But something tells us we haven’t heard the final word on this matter.

Are there long-lasting benefits after a course of tight blood pressure control in type 2 diabetics?

This question was addressed in a recent issue of NEJM in a trial derived from the original United Kingdom Prospective Diabetes Study (UKPDS). The initial UKPD study was a randomized prospective controlled trial of tight versus less-tight blood pressure control in newly diagnosed type 2 diabetics. Of note, the tight blood pressure control group’s goal was a BP of <150/85 mm/Hg and a BP of < 180/105 mmHg in less-tight control cohort.  A significant decrease in any diabetes-related endpoints – diabetes related death, stroke and micro vascular disease – was observed in the tight blood pressure control arm. The current spin-off trial in this week’s NEJM, “Long-term follow-up after tight control of blood pressure in type 2 diabetes”, followed the same cohort post-trial for an average of 8 years. During the post-trial period there were no specific guidelines provided about blood pressure reduction, nor was there an effort to continue the prior study assignment regimen.  Sadly enough, only 2 years after the intervention was discontinued, the previously noted reduction of diabetes-related end points disappeared. However, in a small patient sample there was a significant risk reduction in peripheral vascular disease that persisted 10 years post-intervention. Additionally, the study included a subgroup analysis of patients in the tight blood pressure group who, during the initial trial, were randomized to ACE inhibitor versus beta-blocker based antihypertensive regiments. This in-group analysis showed no statistically significant differences in all endpoints during and post-trial; however, there was an increase in any-cause mortality post-trial in the ACE inhibitor group. Take-home message? In order to reap the benefits of tight blood pressure control in type 2 diabetic patients, maintenance of stringent blood pressure targets must be continuous.

Back to Rhythm control?

Historically a treatment of choice for atrial fibrillation (AF), rhythm control has come under recent scrutiny. Just this past June the NEJM presented convincing data suggesting that the rhythm control approach does not reduce the rate of death from cardiovascular causes in patients with congestive heart failure.  This came as a follow up to the AFFIRM and RACE trials that claimed the rate control strategy to be as successful, if not better, in older patients with AF. So is there still a role for rhythm control? Yes. Rhythm control is still a strategy of choice in patients with poor rate control, ongoing symptoms related to AF and in young patients with new onset AF. Some of the benefits of rhythm control include improvement in cardiac function and quality of life.  At the present time, amiodarone is the preferred drug for rhythm control, with an estimated normal sinus rhythm maintenance in 45-70% of patients. Although the most effective anti-arrhythmic, it is not without side effects. In hopes of diminishing amiodarone-related toxicities (i.e. thyroid, pulmonary, hepatic) an alternative to the continuous strategy, the episodic approach, has been implemented.  In an episodic approach, amiodarone therapy is typically discontinued 1 month post-conversion to sinus rhythm and re-initiated upon recurrence of AF, whereas continuous strategy entails indefinite treatment. A recent randomized controlled trial from the Netherlands published in JAMA compared these two approaches. The outcomes of the study suggest that the continuous strategy was superior to episodic treatment in maintenance of sinus rhythm ( 62% v. 48%) and  prevention of recurrence of AF (54% v 80%).   Additionally, there was a non-significant trend towards lower rates of amiodarone-related adverse events in the episodic group (19% v. 24%), but a higher incidence of heart-related major events (17% v. 9%), all cause mortality and cardiovascular hospitalization (53% v. 34%).  In conclusion, this study supports the continuous amiodarone therapy approach to rhythm control. However, physicians are cautioned to be mindful of amiodarone toxicities and should use clinical judgment in choosing an appropriate rhythm control strategy.

To conclude this week’s ShortCuts, we’d like to mention rhythm once more. This may get you a bit more excited for your next ACLS recertification. And if you lived in the 1970s or are a fan of disco, you really will like what you’re about to read. True to its name, it seems that the catchy and well-known Bee Gees tune, “Stayin Alive” might actually help save lives! In a small study from the University of Illinois medical school, doctors and students maintained close to the ideal number of chest compressions (100 per minute) doing CPR while listening to this song. In this study, 15 students and doctors first performed CPR on mannequins while listening to the song on iPods. They were asked to time chest compressions with the song’s beat. Five weeks later, the drill was repeated without the music but the study subjects were told to think of the song while doing compressions. The average number of compressions the first time was 109 per minute; the second time it was 113. The study’s author, Dr. David Matlock, points out that a few extra compressions per minute is better than too few. He notes that using this song may provide a useful CPR training tool as this life-saving measure is often wrongly performed because people tend to administer compressions too slowly and because people are afraid of not keeping the proper rhythm. This study will be presented at the American College of Emergency Physicians meeting in Chicago this month. What’s likely to follow are larger, more definitive studies with real patients or untrained people. Yes, my friends, just one more reason to love those Gibb brothers.