PrimeCuts: This Week in the Journals

January 19, 2009

lincoln.jpgCommentary  by Aleksandar Adzic MD, PGY-3

Faculty Peer Reviewed

Have you ever been annoyed that the computer systems at the three hospitals you work at are completely different?  Have you ever had trouble piecing together a patient’s medical history who is at your hospital for the first time?  Well President (elect until ~12:00 noon on Tuesday) Obama understands how you feel.  It is no surprise that our “first wired president” (1) has made a bold plan to standardize electronic health records in the next 5 years (2) in order to reduce costs and improve health care for Americans.  He envisions that the plan will create jobs, reduce medical errors, “cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests.” The plan will not be easy to implement and it will not be cheap.  A CNN article states that only 8% of the nation’s 5000 hospitals and 17% of its 800,000 physicians currently use the kind of electronic health records Obama envisions for the whole nation.  Studies estimate that $75 to $100 billion over ten years will be necessary for hospitals to implement the program.  However, compared to the $2 trillion a year spent on healthcare, the plan could save $200 to $300 billion a year.  The lack of highly skilled health information technology professionals and the growing discussion about privacy issues (3) of the new system are questions yet to be solved.

Focusing on prevention has been another idea often suggested to curtail rising healthcare costs.  An article from Circulation this week (4)  addressed the relationship of individual and combined effects of BMI and vigorous physical activity(enough exercise to break a sweat 1 to 3 times a month) and the risk of heart failure (HF) in a prospective cohort of 21,094 men with mean age 53 years without known coronary heart disease from the Physicians’ Health Study.  The data, with mean follow up of 20.5 years, showed that after adjustment for established risk factors for HF, every 1 kg/m2 increase in BMI was associated with an 11% increase in risk of HF i.e., increasing categories of BMI were associated with increasing risk of HF.  Compared to lean patients (BMI <25), overweight and obese patients had a 49% and 180% increase in HF risk, respectively.  Vigorous physical activity produced an 18% decrease in HF risk and increasing levels of vigorous activity were associated with a graded reduction in the risk of HF.  The study suggests that public health measures to curtail excess weight and promote physical activity may limit the healthcare burden of CHF.

Speaking of cardiovascular disease, the NEJM this week carries an article that explores whether fractional flow reserve (FFR) measurement in addition to angiography improves outcomes in patients with multivessel CAD undergoing PCI (8) .  For patients with multivessel disease, determining which lesions to stent is difficult and stress imaging is limited in localizing ischemia-producing lesions.  FFR is the ratio of maximal blood flow in a stenotic artery to maximal blood flow (ratio of distal coronary pressure to aortic pressure measured during cath).  An FFR in a normal coronary is 1.0 while a value of <0.80 identifies ischemia-causing stenoses.  1005 patients had lesions for PCI identified by angiography and were then randomized into PCI only vs. FFR guided PCI (only for lesions <0.80).  The primary endpoint was the rate of major adverse cardiac events at 1 year (composite of death, MI and repeat revascularization).  Results revealed that FFR during PCI as compared to standard PCI significantly reduced the rate of the primary composite end-point at 1 year (13.2 vs. 18.3%), required less stents (1.9 vs. 2.7), required less contrast agent, and cost less ($5,332 vs. $6,007). The combination of the rate of death and MI was also significantly reduced.  This trial shows that using FFR with PCI compared to PCI alone has a NNT of 20 to prevent one adverse event and suggests that PCI should be guided by physiological considerations (FFR <0.80 being indicative of a stenosis inducing ischemia) rather than just anatomical ones.

Another great concern for the upcoming administration as they seek to control healthcare costs is the growing segment of the population who reside in nursing homes and the costs associated with their care.  A UK study (5) points out that antipsychotics are used frequently in nursing home sufferers of Alzheimer’s dementia to control neuropsychiatric symptoms, commonly for longer than a year.  This randomized, placebo-controlled, trial found that continued treatment with antipsychotics in dementia patients for 12 months vs. switch to placebo was associated with higher mortality (with more pronounced differences evident at 24 and 36 months), highlighting the need for less harmful alternatives to long term antipsychotic treatments.  Risperidone and haloperidol were the antipsychotics used for mostly in this study, but another study in this week’s NEJM focused on atypical antipsychotics and the risk of sudden cardiac death (SCD) associated with their use(6).  An increased risk of QT prolongation causing ventricular arrhythmias that lead to SCD is a feature of typical antipsychotics, but less is known about the cardiac safety of atypical antipsychotics that have replaced them because of a better movement disorder profile.  This was a large retrospective cohort study of Medicaid enrollees in Tennessee that demonstrated that current users of typical and atypical antipsychotics had higher rates of SCD (adjusted incidence ratios of 1.99 and 2.26 respectively) than did non-users of antipsychotics.  It also demonstrated that current users of atypical antipsychotics had a dose-dependent increase in the risk of SCD that was essentially identical to that of typical antipsychotic users.

Finally, as someone with a peanut allergy, I know all too well the dangers of these tasty legumes, but recently(7) peanuts have become even more deadly.  Last week products of the Peanut Corporation of America’s Georgia factory were found to be contaminated by salmonella that could be related to the illness of 474 people in 43 states and 6 deaths.  FDA officials urge consumers to avoid eating cakes, candies, crackers, cookies and ice cream made with peanut products until it is certain they are not from the contaminated batches. The FDA warning does not include peanut butter sold in jars, which currently appears to be safe to eat.





  4. Body Mass Index and Vigorous Physical Activity and the Risk of Heart Failure Among Men.  Satish Kenchaiah, Howard D. Sesso, and J. Michael Gaziano.  Circulation. 2009;119:44-52; published online before print December 22 2008, doi:10.1161/CIRCULATIONAHA.108.807289

  5. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial.Ballard C et al.  Lancet Neurol. (2009)

  6. Atypical antipsychotic drugs and the risk of sudden cardiac death.  Ray WA, Chung CP, Murray KT, Hall K, Stein CM.  N Engl J Med. 2009 Jan 15;360(3):225-35.


  8. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention.Tonino PA et al. N Engl J Med. (2009)

Reviewed by Cara Litvin MD, Executive Editor, Clinical Correlations