APR 8, 2016

Through the wire

The story

Poor surgical candidates with severe aortic stenosis have been transcatheter aortic valve replacement (TAVR) magnets for years. Now the PARTNER investigators, forerunners of all things TAVR, are bringing the procedure to the masses.

The basics

Similar to cardiac caths that place stents in arteries, TAVR delivers a replacement valve to the existing valve site through a catheter. The original PARTNER trial in 2010 evaluated TAVR use in patients with contraindications to surgery and found a reduction in all-cause mortality from 68% to 43% at 2 years. Known complications include stroke, paravalvular leak, and heart block requiring pacemaker insertion.

The results

Fresh from the American College of Cardiology annual meeting, PARTNER 2 compared intermediate surgical risk candidates in an RCT of TAVR vs. surgical aortic valve replacement. TAVR was non-inferior to surgery with regard to mortality and disabling stroke rates (19 vs 21%, favoring TAVR) at 2 years post-procedure.

The new valve in town

PARTNER 2 looked at the Sapien XT valve. A newer valve, the Sapien 3, has a narrower crimped frame that helps operators access femoral vessels and avoid more risky transthroacic approaches. In a tricky, not-quite-RCT analysis, investigators looked at a year of observational outcomes data in Sapien 3 patients and compared them to matched patients in the surgical arm of the PARTNER 2 trial. The Sapien 3 group had fewer episodes of death, stroke, and valve regurgitation than the surgical group. 

The takeaway

The future is here, and it’s full of TAVRs. The PARTNER investigators plan to study TAVR in low-risk surgical candidates next.

Say it on rounds

When you need a miracle to get to work on time

It never hurts to hope. Prior trials evaluating the role of statins in primary prevention of coronary disease mostly focused on white men with high cholesterol or inflammatory markers. HOPE-3 looked at statin use in ethically diverse men and women from 6 continents with intermediate risk of coronary disease. Daily rosuvastatin decreased cardiovascular events 24% (absolute difference 1.1%) relative to placebo and also decreased rates of stroke. The researchers suggest that single pill administration can decrease disease burden in large segments of the world.

When what you see on the wards makes you lose your appetite

Gross stuff in the hospital has not yet proven to be an effective weight loss tool, but bariatric surgery is the real deal. An observational cohort study of over 2,000 patients who underwent bariatric surgery found significant improvements in pain and physical function after surgery in 50 - 70% of patients. The results were most striking at one year, but improvements continued for 3 years post-op, especially in knee pain and 400m walking speed.

When cardiologists and hematologists get down to business

Things get weird, and then magic happens. And here the magic is intramyocardial ixmyelocel-T. In a Phase III RCT, this therapy derived from patients' own bone marrow – a mix of CD90+ stem cells and CD45/CD14 activated macrophages, if you're curious – reduced cardiac events by 37% when compared to placebo in patients with severe heart failure due to ischemic dilated cardiomyopathy.

When initial results seem too good to be true

Long-term follow-up helps. A prospective cohort study that began in 1992 found that self-reported ejaculation frequency was inversely correlated with prostate cancer incidence at 8 years. The new 18-year results found a significantly decreased incidence of prostate cancer for those who reported ejaculating > 21 times per month in the 20 - 29 and 40 - 49 age groups. Some theorize that carcinogens accumulate in the prostate and are flushed by ejaculation, but 15-year-old boys seem to have bought into the data without asking questions.
Eur Urol

Brush up

Contrast induced nephropathy (CIN)

CIN is defined as an increase in creatinine by more than 25% within 48 - 96 hours of IV contrast administration. Risk factors include CKD, diabetes, hypertension, and elderly age. Exclude other causes of kidney injury and focus on prevention for high risk patients to avoid prolonged hospitalization and associated costs.

What's the evidence

For strategies to prevent CIN? 2011's ACT showed no difference in CIN rates with n-acetylcystine (NAC) administration prior to angiography. A meta-analysis covering all adults that received IV contrast showed benefit when NAC was added to IV fluids or statins. Patients also fared better when low osmolar contrast media was used. 

Dollar dollar bills

2016 physician compensation surveys show it's good to be an orthopedist and not as good to be a pediatrician. Rheumatologist and internists saw their incomes increase 12%, while allergists and pulmonologists took home less pay. North Dakota pays its doctors the most, Rhode Island the least, and a gender gap in pay remains sizable. 

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