May 25, 2018

Fame monster

The story

Residency is about learning how to clean up someone else's mess in the nick of time, but the last-minute fix has its hazards. New research looks at early vs. late intervention in coronary artery disease (CAD). 

The flow

Your day runs smoother when you have a little bit of time to plan. We'd imagine the same holds true for cath lab procedures run electively. For patients with stable angina, fractional flow reserve (FFR) can be used during angiography to identify and intervene on lesions that are limiting coronary blood flow and causing ischemia. Cardiologists have debated for years whether myocardial infarctions (MIs) come from these kind of lesions getting worse over time or from abrupt occlusions at sites of otherwise mild, non-flow-limiting disease.

The fame

FAME 2 pitted upfront PCI for hemodynamically significant stenoses (FFR < 0.80) against optimal medical therapy in 1,200 patients with stable CAD. Five-year outcomes favored the PCI group, though the difference in the primary endpoint – a composite of urgent revascularization, MI, and death from any cause – was driven mostly by a reduced rate of urgent revascularization favoring early stents. While not statistically significant, there was a strong trend towards reduced MI in the PCI group, who also reported greater relief from angina.

The takeaway

FAME 2 argues that, when left alone, significant stenoses can cause problems later. Since about half of the patients in the medical therapy group received stents during the follow-up period, there's a good chance your stable CAD patients are headed toward PCI regardless of approach.

Say it on rounds

When your clinical intuition has a superstitious feel

Omens are everywhere. An analysis of the 1,700-patient Italian Pulmonary Embolism Registry found that patients with acute PE who presented with syncope or pre-syncope faced a dramatically higher risk of 30-day mortality (43% vs. 6%) compared to other initial presentations. Pre-syncope held as an independent predictor of mortality regardless of other factors like right ventricular dysfunction, age, and thrombolysis. The study highlights this group, who make up a quarter of initial presentations for acute PE, as especially high-risk.
Eur J Intern Med

When one glove is just not going to do the trick

It's time to double up. Several trials have looked at whether the benefits of dual-antiplatelet therapy (DAPT) following acute stroke outweigh the increased risk of bleeding. POINT, the latest to weigh in, compared DAPT with aspirin and clopidogrel to aspirin plus placebo in 4,800 stroke and TIA patients. At 90-day follow-up, DAPT reduced major strokes by 35% (6.3 vs 4.6%) but doubled the rate of major hemorrhage (0.9% vs 0.4%). Since most of the benefit for DAPT was seen in the first 7 days after stroke, we may see a clinical trend toward short-term DAPT for most patients.

When others count sheep, and you count honking horns

Things get a bit twisted in the big city. But when it comes to reading on your iPad before bed, a lab-based study of 9 volunteers found that electronic devices delayed sleep onset, prompted later bedtimes, and suppressed melatonin compared to traditional print reading. Study volunteers, who spent 10 nights in a sleep lab split evenly between each reading method, also had fewer periods of REM sleep with electronic devices. No word yet on how Kindles fit in.
Physiol Rep

Brush up

Pulmonary arterial hypertension

Look for pulmonary arterial hypertension (PAH) in young women who present with dyspnea, reduced exercise tolerance, and exertional syncope. The disease is rare, but 5-year mortality approaches 50%. Diagnosis rests on a right heart cath documenting pulmonary artery pressure of 25 mm Hg or above. Many drug classes – prostaglandins, phosphodiesterase-5 inhibitors, endothelin receptor antagonists, and others – are used to vasodilate the pulmonary arteries and improve functional capacity.

What's the evidence

For upfront combination therapy in PAH? 2015's AMBITION trial found that combining the endothelin receptor antagonist ambrisentan and the PDE5 inhibitor tadalafil improved symptoms and functional status compared to either drug alone in treatment-naive patients with PAH. The trial failed to prove a mortality benefit for combination therapy, which remains an elusive endpoint in this disease.

What your geology friends are talking about

Hawaii's Kilauea has been spewing lava since May 3. Here's a look at fire and flames, and how the USGS Hawaiian Volcano Observatory has kept local residents safe during the eruption.  

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