PrimeCuts – This Week in the Journals

November 6, 2017


By Nicole Massucci, MD

Peer Reviewed

This week, President Trump embarks on a two-week trip visiting 5 Asian countries in hopes of rallying efforts to increase pressure on North Korea (1). The trip comes after a week of controversy; between Donna Brazile revealing details of the Clinton campaign rigging the DNC, and the Republican Party proposing the biggest overhaul of the U.S. tax code in 3 decades (2,3).

Keep reading for this week’s highlights from the medical literature.

No difference in exercise improvement between PCI and placebo in patients with medically treated angina

Many patients with stable angina have symptoms despite medical optimization, and thus opt for PCI as second line treatment. In a blinded, randomized, placebo-controlled trial, researchers compared the effect of PCI versus a placebo procedure on exercise capacity in patients with stable angina and anatomically and hemodynamically severe coronary stenosis (4).

After a 6 week medical optimization period, 200 patients with stable angina and angiographically confirmed coronary vessel stenosis were blinded and randomized to receive either complete revascularization with PCI or a placebo procedure. The patients receiving the placebo procedure underwent diagnostic angiography and then were kept sedated for 15 minutes in the cath lab with the coronary catheters removed. The primary endpoint was change in exercise time between the groups. There was no significant difference in increased exercise time between the groups (PCI minus placebo increment 16.6 seconds, 95% CI -8.9 to 42.0, p= 0.200).

This study is unique in that it is the only blinded placebo-controlled randomized trial of PCI for stable angina, thus eliminating the placebo effects that are inherently larger for invasive treatments. While it is plausible to linearly link our patients’ anginal symptoms to the degree of stenosis and expect resolution of symptoms after reversal of the stenosis, this study implies that there exists a more complex interplay of anatomy, physiology, and manifestation of symptoms not so easily resolved. Furthermore, this study calls into question the role of PCI for treatment of symptomatic stable angina. 

PCI of culprit vessel only has better outcomes than multivessel PCI in acute MI patients with cardiogenic shock

It is well known that in acute MI complicated by cardiogenic shock, early revascularization with percutaneous coronary intervention (PCI) or CABG is superior to medical management (5). Despite these advances, mortality due to cardiogenic shock complicated by MI remains high (~50%) and many of these patients have multivessel coronary artery disease (6,7). While PCI of the culprit lesion is the standard of care, the management of non-culprit lesions is widely debated.

In a recent study published in the NEJM, 706 patients with acute MI complicated by cardiogenic shock were randomized to the culprit-lesion-only PCI group or complete revascularization with PCI (8). The primary end point was a composite of death from any cause or severe renal failure requiring renal-replacement therapy within 30 days of randomization. Safety end points included bleeding and stroke.

At 30 days, the rate of the composite primary end point of death or renal replacement therapy was significantly lower in the culprit-lesion-only PCI group (45.9%) than in the multivessel PCI group (55.4%; RR, 0.83; 95% CI, 0.71 – 0.96; P=0.01). The rates of recurrent MI, rehospitalization for CHF, bleeding, and stroke did not differ among the groups.

A major strength of this study was the inclusion of chronic total occlusive disease which is commonly present in patients with cardiogenic shock and was an exclusion criteria of other similar studies leading to selection bias. Some limitations include the inability for blinding and the variability in management of cardiogenic shock that is largely provider dependent.

This study found that among patients with multivessel CAD and acute MI complicated by cardiogenic shock, the risk of death or renal replacement therapy was lower among patients who had initially undergone PCI of culprit vessel only. These findings are in contrast to previous studies that showed lower mortality rates in the multivessel PCI groups.

Patient navigation combined with financial incentive for smoking cessation more effective than traditional counseling in low socioeconomic status population

Overall, the prevalence of smoking has been decreasing; however, socioeconomic disparities persist. Patients of low socioeconomic status(SES) continue to have higher smoking rates despite population-based advances in smoking cessation such as free access to counseling and tobacco price increases (9). In a new study published last week, researchers at Boston Medical Center sought to assess a multi-component method of encouraging smoking cessation in a low SES and minority population (10).

The study randomized 352 active smokers not already receiving smoking cessation treatment into 1 of 2 groups: enhanced traditional counseling (control) or patient navigation and financial incentives. The control group received a brief counseling session and smoking cessation materials. The intervention group received a combination of financial incentives and patient navigation in addition to the materials in the control group.

Patient navigators were trained to adhere to a script incorporating motivational interviewing while they actively coordinated treatment for participants who expressed interest. The intervention group was also offered financial compensation for biochemically confirmed smoking cessation at 6 and 12 months after study enrollment.

The primary outcome of the study was biochemically confirmed smoking cessation at 6 and 12 months. The odds ratio for quitting at 12 months was significantly higher in the navigation and incentive group than in the control group in the unadjusted model (OR, 5.76; 95% CI, 1.93-17.13).

Among participants in the intervention group those who received the minimum dose of patient navigation (defined by completion of the motivational interview based script) were more likely to have quit smoking by 12 months. This outlines the importance of motivational interviewing when it comes to counseling our patients on health improving habits. Perhaps more interesting was the fact that not a single white participant in either arm of the study had quit smoking. The researchers speculated this could be related to race discordance with the patient navigators, or due to differences in physiologic response to NRT vs pharmacotherapy.

Risks associated with triathlon participation higher than expected annual risk of death for middle aged persons

Triathlons have become increasingly popular over the years since their origin in the 1970’s; however, race-related fatalities have raised the question of safety. Given the rapid growth of triathlon participation, it is important to understand the frequency and demographics of the risks associated with this evolving sport. In a recent case series published in Annals of Internal Medicine, researchers set out to describe death and cardiac arrest rates among participants (11).

Over 9 million U.S. triathlon participants between 1985 and 2016 were studied and a total of 135 sudden deaths, cardiac arrests, and trauma-related deaths occurred. The mean age of the victims was 46.7 and 85% were male. Specifically, the rate of death or arrest of middle-aged and older men (> 40 years old) was 3.3 times higher than younger males. Most of the sudden deaths and cardiac arrests occurred during the swim portion (67%). The incidence of death or cardiac arrest among participants was 1.74 per 100,000 (2.40 in men and 0.74 in women per 100,000; P < 0.001), which is higher than earlier estimates.

There was a surprisingly high frequency of clinically silent cardiac disease (50% of autopsies performed) that may have contributed to the sudden cardiac deaths, with atherosclerotic coronary disease predominating. Interestingly, the incidence of cardiovascular-related death in women was 3.5 times lower than in men.

The study concluded that the risk associated with participating in a triathlon exceeds the expected annual risk for sudden death for a middle-aged person. This begs the question of whether any of the deaths could have been prevented. Triathlon participants, unlike high school and college athletes, are not required to undergo screening examinations. These findings suggest that it may be beneficial for some patient populations to get screened before entering triathlon competitions, particularly men over the age of 40.

Mini-Cuts

We know that moderate alcohol use is associated with lower risk of CVD in the general population, however one study found that this is not the case in patients with non-alcoholic fatty liver disease (12).

Fecal immunochemical testing is often limited by failure to obtain follow-up colonoscopy after positive results. This systematic review investigated which interventions improved colonoscopy rates (13).

A cohort study of training physicians found a marked increase in depressive symptoms during internship year, with a greater increase for women (14).

Dr. Nicole Massucci, is 1st year Internal Medicine Resident at NYU Langone Health.

Peer Reviewer by Dr. Ian Henderson, a Chief Resident in Internal Medicine, NYU Langone Health

Image courtesy of Forbes.com

References

  1. Liptak, K. (2017, November 04). Trump arrives in Japan, first in five-country Asian tour. Retrieved November 05, 2017, from http://www.cnn.com/2017/11/04/politics/trump-tokyo-asia-trip-shinzo-abe/index.html
  2. Brazile, D., DOVERE, E., Alberta, T., Bernstein, D., Dovere, E., & Glasser, S. B. (2017, November 02). Inside Hillary Clinton’s Secret Takeover of the DNC. Retrieved November 05, 2017, from https://www.politico.com/magazine/story/2017/11/02/clinton-brazile-hacks-2016-215774
  3. Paletta, D., & DeBonis, M. (2017, November 2). GOP tax plan would shrink mortgage interest benefit, slash corporate tax rate. Retrieved November 5, 2017, from https://www.washingtonpost.com/business/economy/republican-tax-plan-to-lower-cap-on-mortgage-interest-deduction-to-500000-loans/2017/11/02/c0f594d6-bfd5-11e7-8444-a0d4f04b89eb_story.html?utm_term=.1638312c0028
  4. Al-Lamee, R., & Thompson, D. (2017). Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. The Lancet. http://dx.doi.org/10.1016/ S0140-6736(17)32714-9 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32714-9/abstract
  5. Hochman, J. S., Sleeper, L. A., Webb, J. G., Sanborn, T. A., White, H. D., Talley, J. D., Lejemtel, T. H. (1999). Early Revascularization in Acute Myocardial Infarction Complicated by Cardiogenic Shock. New England Journal of Medicine,341(9), 625-634. doi:10.1056/nejm199908263410901
  6. Hochman, J. S. (2003). Cardiogenic Shock Complicating Acute Myocardial Infarction: Expanding the Paradigm. Circulation,107(24), 2998-3002. doi:10.1161/01.cir.0000075927.67673.f2 http://circ.ahajournals.org/content/107/24/2998
  7. Thiele, H., Desch, S., Piek, J. J., Stepinska, J., Oldroyd, K., Serpytis, P., & Zeymer, U. (2016). Multivessel versus culprit lesion only percutaneous revascularization plus potential staged revascularization in patients with acute myocardial infarction complicated by cardiogenic shock: Design and rationale of CULPRIT-SHOCK trial. American Heart Journal,172, 160-169. doi:10.1016/j.ahj.2015.11.006 http://www.sciencedirect.com.ezproxy.med.nyu.edu/science/article/pii/S0002870315006638#bb0050
  8. Thiele, H., Akin, I., Sandri, M., Fuernau, G., Waha, S. D., Meyer-Saraei, R., & Zeymer, U. (2017). PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. New England Journal of Medicine. doi:10.1056/nejmoa1710261 http://www.nejm.org.ezproxy.med.nyu.edu/doi/full/10.1056/NEJMoa1710261
  9. Jamal, A., King, B. A., Neff, L. J., Whitmill, J., Babb, S. D., & Graffunder, C. M. (2016). Current Cigarette Smoking Among Adults — United States, 2005–2015.  Morbidity and Mortality Weekly Report,65(44), 1205-1211. doi:10.15585/mmwr.mm6544a2
  10. Lasser, K. E., Quintiliani, L. M., Truong, V., Xuan, Z., Murillo, J., Jean, C., & Pbert, L. (2017). Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital. JAMA Internal Medicine. doi:10.1001/jamainternmed.2017.4372
  11. Harris, K. M., Creswell, L. L., Haas, T. S., Thomas, T., Tung, M., Isaacson, E., & Maron, B. J. (2017). Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016. Annals of Internal Medicine, 167(8), 529. doi:10.7326/m17-0847
  12. Vanwagner, L. B., Ning, H., Allen, N. B., Ajmera, V., Lewis, C. E., Carr, J. J., & Siddique, J. (2017). Alcohol Use and Cardiovascular Disease Risk in Patients With Nonalcoholic Fatty Liver Disease. Gastroenterology, 153(5). doi:10.1053/j.gastro.2017.08.012
  13. Selby, K., Baumgartner, C., Levin, T. R., Doubeni, C. A., Zauber, A. G., Schottinger, J., & Corley, D. A. (2017). Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests. Annals of Internal Medicine, 167(8), 565. doi:10.7326/m17-1361
  14. Guille, C., Frank, E., Zhao, Z., Kalmbach, D. A., Nietert, P. J., Mata, D. A., & Sen, S. (2017). Work-Family Conflict and the Sex Difference in Depression Among Training Physicians. JAMA Internal Medicine. doi:10.1001/jamainternmed.2017.5138