Oct 5, 2018

Even flow

The story

Wearing your scrubs to a Halloween party is one way to bore people. Presenting the day’s 5th heart failure admission is another. Can a mitral valve procedure keep patients out of the hospital?

An old device

In today’s world of cardiology uber-tech, transcatheter mitral valve repair (TMVR) isn’t exactly new. The FDA approved the MitraClip – a device that basically seals gaps in leaky valve leaflets (see video) – in 2013 for patients with primary severe mitral regurgitation (MR) who were not candidates for surgery. But the role for TMVR may be much larger: secondary, or functional, MR affects over half of patients with left ventricular dysfunction and is more common than primary MR. Surgery has never been shown to improve outcomes in this group. 

A new result

TMVR reduced all-cause mortality compared to medical therapy alone in heart failure patients with severe secondary MR who remained symptomatic despite maximal medical therapy. The 600-patient COAPT trial found that after 24 months TMVR nearly cut the annualized rate of hospitalizations in half (36% in the device group vs. 68% in controls) and reduced death from any cause by one third (29% vs. 46%). NNTs for hospitalizations and mortality were 3 and 6, respectively. The results dramatically outperformed prior TMVR studies, which experts attributed to operator experience (procedural complications were low) and careful patient selection criteria.

The takeaway

With outcomes that are almost too good to be true, longer follow-up for COAPT will be watched carefully. In the meantime, many of your heart failure patients will be TMVR candidates.

Say it on rounds

When the new cards fellow makes you blush

Too shy to open up? You may not have to. APPAC randomized 530 patients with uncomplicated acute appendicitis to receive surgery or 3 days of IV antibiotics followed by 7 days of oral meds. While only 6% of patients in the antibiotic arm required surgery during the initial hospitalization period, the overall 5-year recurrence rate was 39%. Hospital length of stay was similar between groups, though surgical patients missed more time from work, possibly because surgery was open rather than laparoscopic.

When giving up pizza is off limits

It's not for everyone, but for the zealots out there total diet replacement (TDR) is an intriguing option. An RCT of 280 obese patients found that TDR with 810 calories per day of formula food (shakes, bars, and soups) for 8 weeks led to sustained weight loss compared to a standard diet program. At 1 year, 45% of patients in the intervention arm lost more than 10% of body weight vs. 15% in the control arm. More patients in the TDR group reported adverse events (AE), but there was no difference in moderate or severe AEs.  

When intern enthusiasm seems a bit watered down

Maybe for the best. An open-label RCT of 140 women with recurrent urinary tract infections (UTIs) and poor water intake (< 1.5L daily) found that increasing drinking water reduced subsequent UTIs. Participants randomized to add 1.5L of water to their usual daily intake had an average of 1.7 UTIs per year compared to 3.2 in patients with no additional fluid intake. The benefits are thought to spring from flushing and dilution of bacteria in the urinary tract.
JAMA Int Med

Brush up

Age-related macular degeneration

About 13% of patients over age 85 have age-related macular degeneration (AMD), with white race and female sex at highest risk. Fatty drusen lesions deposit in the macula and cause central vision loss. Early diagnosis is key, so look for patients who report distorted vision while reading, driving, or watching TV. Difficulty recognizing faces or complaints about a dark patch over the eye are other important clues. Symptoms may not be apparent if only one eye is affected.

What's the evidence

For the use of antioxidants in early-stage AMD? A 2017 Cochrane review of 19 studies found that antioxidant vitamin supplements modestly slowed the progression of AMD from early to late-stage disease. High-dose zinc had the strongest protective effect. A similar review by the same team found no evidence that antioxidants prevent the initial development of AMD.

What your Down Under friends are talking about

Look to the Southern Hemisphere to take your mind off of fiery debates at home. A 'period leave' introduced by an Australian women's advocacy organization has sparked conversation around the world. 

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