Physician's First Watch: Archives

News from AHA 2009

This week, Journal Watch Cardiology, Journal Watch Psychiatry, and Physician's First Watch have been bringing you breaking news from the American Heart Association meeting in Orlando. Please have a look (most of the studies were presented at the meeting and published in peer-reviewed journals at the same time):

Journal Watch Cardiology summary of ARBITER 6 trial showing niacin superior to ezetimibe (Free)

Physician's First Watch ARBITER coverage (Free)

Journal Watch Cardiology summary of cangrelor study — a setback for the antiplatelet agent (Free)

Journal Watch Cardiology summary of study on right-ventricular pacing (Your Journal Watch subscription required)

Physician's First Watch coverage of study on ECG findings and cardiac death (Free)

Journal Watch Cardiology summary of study on high-dose losartan in heart failure (Your Journal Watch subscription required)

Physician's First Watch coverage of losartan study (Free)

Journal Watch Cardiology summary of study on iron for heart failure patients (Your Journal Watch subscription required)

Journal Watch Cardiology summary of study on continuous LV assistance for heart failure (Your Journal Watch subscription required)

Journal Watch Psychiatry summary of study on treating depression after CABG (Your Journal Watch subscription required)

Published in Physician's First Watch November 18, 2009

Early Repolarization in Inferior Leads Might Signal Trouble Ahead

J-point elevation in the inferior leads of a standard 12-lead electrocardiogram "is not an innocuous finding in middle-aged subjects," according to a New England Journal of Medicine report released online.

Using national databases to assess outcomes in some 11,000 Finnish patients followed for an average of 30 years after a baseline ECG, researchers noted the following:

• J-point elevation occurred in roughly 6% of subjects (3.5% in inferior leads and 2.4% in lateral leads).
  
• Elevations in inferior leads were most often found among men and smokers.
  
• J-point elevations of 0.1 mV in inferior leads were associated with significantly higher adjusted risks for death from cardiac causes (relative risk, 1.28) and arrhythmia (RR, 1.43).
  
• Elevations of more than 0.2 mV in inferior leads were associated with a higher risk for death from any cause (RR, 1.54) and markedly higher risks for cardiac death (RR, 2.98) and arrhythmia (RR, 2.92).
  
• Elevations in lateral leads were only of borderline significance.
  

LINK(S):

NEJM article (Free)

Journal Watch Cardiology summary of 2008 NEJM study on early repolarization (Your Journal Watch subscription required)

Published in Physician's First Watch November 17, 2009

USPSTF Recommends Against Routine Mammography for Women in Their 40s

The U.S. Preventive Services Task Force now recommends against routine screening mammography for average-risk women aged 40 to 49. This represents a change from the USPSTF's 2002 recommendation statement, which advocated for routine screening starting at age 40.

Among the task force's other updates, published in Annals of Internal Medicine:

• Screening mammography should be performed every 2 years for average-risk women aged 50 to 74.
  
• Evidence is insufficient to recommend for or against screening in women 75 or older.
  
• Clinicians should not teach women how to perform breast self-exams.
  
• Evidence is insufficient to make recommendations on using clinical breast exams in addition to mammography.
  
• Evidence is insufficient to recommend for or against using digital mammography or MRI instead of film mammography.
  

In Journal Watch Women's Health, Dr. Andrew Kaunitz says that because the updated guidelines recommend less screening, women may be confused or even outraged. He calls for consistent "frank discussions" with patients about the benefits and risks of screening mammography.

(The American College of Radiology has spoken out against these guideline changes.)

LINK(S):

Annals of Internal Medicine article (Free)

Annals of Internal Medicine editorial (Subscription required)

Journal Watch Women's Health clinical practice guideline watch (Free)

American College of Radiology statement opposing USPSTF's changes (Free)

Published in Physician's First Watch November 17, 2009

H1N1 Update: New Vaccine Approved in U.S.

The FDA has approved a fifth vaccine for 2009 H1N1 influenza for use in adults. GlaxoSmithKline says it expects to begin shipments in December.

LINK(S):

FDA news release (Free)

GlaxoSmithKline news release (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch November 17, 2009

News from AHA 2009

This week, Journal Watch Cardiology and Physician's First Watch are bringing you breaking news from the American Heart Association meeting in Orlando. Please have a look (most of the studies were presented at the meeting and published in peer-reviewed journals at the same time):

Journal Watch Cardiology summary of ARBITER 6 trial showing niacin superior to ezetimibe (Free)

Physician's First Watch ARBITER coverage (Free)

Journal Watch Cardiology summary of cangrelor study — a setback for the antiplatelet agent (Free)

Journal Watch Cardiology summary of study on right-ventricular pacing (Subscription required)

Physician's First Watch coverage of study on ECG findings and cardiac death (Free)

Published in Physician's First Watch November 17, 2009

Extended-Release Niacin Outperforms Ezetimibe in Lowering Cardiovascular Risk

In patients with high cardiovascular risk, extended-release niacin is associated with better outcomes than ezetimibe, according to a New England Journal of Medicine study released online.

Researchers randomized over 350 patients on long-term statins to added therapy with either niacin or ezetimibe. The primary endpoint was the difference in change of carotid artery intima–media thickness from baseline to 14 months between groups. After 208 patients had completed the trial, it was stopped when results significantly favored niacin.

Two accompanying editorials bemoan the trial's early end, arguing that all patients studied up to the point of stoppage should have been analyzed, not just those who completed 14 months' therapy. Nonetheless, both support the use of niacin over ezetimibe in high-risk patients, and both point to trials, now under way, that may provide more definitive results. In Journal Watch Cardiology, Dr. Harlan Krumholz says that these results "will not be available for many years. In the meantime, ezetimibe should be a drug of last resort, if it is used at all."

LINK(S):

NEJM article (Free)

NEJM editorial by Blumenthal and Michos (Free)

NEJM editorial by Kastelein and Bots (Free)

Journal Watch Cardiology summary (Free)

Published in Physician's First Watch November 16, 2009

FDA Approves Drug for Menorrhagia, with a Warning

The FDA on Friday announced approval of Lysteda (tranexamic acid) tablets as the first nonhormonal product to treat menorrhagia. It warns, however, that use of the drug while taking hormonal contraceptives may increase the risk for thrombi, stroke, and myocardial infarction.

Tranexamic acid, a derivative of the amino acid lysine, blocks lysine-binding sites on plasminogen, thus blocking fibrinolysis. It was first approved in the 1980s to prevent excessive bleeding during tooth extraction in patients with hemophilia.

LINK(S):

FDA news release (Free)

Physician's First Watch coverage of guidelines for managing reproductive tract bleeding (Free)

Physician's First Watch coverage of IUD for menorrhagia (Free)

Published in Physician's First Watch November 16, 2009

News from AHA 2009

This week, Journal Watch Cardiology and Physician's First Watch will be bringing you breaking news from the American Heart Association meeting in Orlando. Please have a look (most of the studies were presented at the meeting and published in peer-reviewed journals at the same time):

Journal Watch Cardiology summary of ARBITER 6 trial showing niacin superior to ezetimibe (Free)

Physician's First Watch ARBITER coverage (Free)

Journal Watch Cardiology summary of cangrelor study — a setback for the antiplatelet agent (Free)

Journal Watch Cardiology summary of study on right-ventricular pacing (Subscription required)

Published in Physician's First Watch November 16, 2009

H1N1 Update: Estimates of Flu's Toll; Seasonal Vaccine Not Effective Against 2009 H1N1

Reports on 2009 H1N1 influenza in the U.S. will now use estimates from the CDC's Emerging Infection Program, rather than counting only laboratory-confirmed cases, according to a CDC news briefing.

The new estimates for the first 6 months of the pandemic — from mid-April to mid-October — find that:

• Roughly 22 million people in the U.S. became ill from the virus.
  
• Nearly 100,000 were hospitalized.
  
• Some 3900 died, including an estimated 540 children under 18; some 2900 adults between 18 and 64; and 440 elderly.
  

This week's MMWR carries a CDC analysis concluding that the seasonal trivalent vaccine offers no protection from — or increased risk for — 2009 H1N1 disease. An additional surveillance article on the pandemic notes that "severe outcomes among children ... continue to be prominent" and provide support for the recommendation that those aged 6 months to 24 years be targeted for vaccination.

Also on Thursday, the FDA granted accelerated approval for the use of CSL Limited's 2009 H1N1 influenza vaccine in children 6 months and up. The vaccine had previously been indicated for adults.

LINK(S):

CDC estimates of cases, hospitalizations, and deaths (Free)

MMWR article on influenza surveillance (Free)

MMWR article on vaccine effectiveness (Free)

CDC news briefing transcript (Free)

FDA news release on H1N1 vaccine approval for children (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch November 13, 2009

No Clinical Benefits of Revascularization in Atherosclerotic Renal Arteries

Revascularization for atherosclerotic renovascular disease, performed in over 15% of such patients in the U.S., shows "no evidence of a worthwhile clinical benefit," according to a New England Journal of Medicine study.

The ASTRAL investigators studied outcomes in some 800 patients, half of whom had been randomized to undergo revascularization in addition to receiving usual medical therapy. After a median follow-up of almost 3 years, there was less deterioration in renal function among those who underwent revascularization. However, the authors say the benefits "were below levels that would be considered clinically relevant."

No improvements in blood pressure, or reductions in renal or cardiovascular events or mortality were seen with revascularization. On the other hand, the procedure was associated with severe complications.

One of the main limitations of their study, the authors say, is that they excluded people with severe renal artery stenosis who, in their doctors' opinion, required revascularization, yet they point out that "the widespread use of such procedures outside of clinical trials can now be questioned."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

Published in Physician's First Watch November 12, 2009