Sep 8, 2017

Heart's content

The story

So you missed a trip to the European Society of Cardiology's annual meeting in Barcelona in favor of weekend long call in the ICU? Us too. We've got you covered with our favorites from the conference.

Thin out

Mixing up interns is easy. Mixing antithrombotic agents in heart disease? Harder. The 27,000 patient COMPASS trial evaluated aspirin combined with low-dose rivaroxaban (Xarelto) vs. aspirin alone in patients with stable coronary or peripheral artery disease. The trial was stopped early after the rivaroxaban-aspirin group had fewer cardiac events and fewer deaths than the aspirin group. While the dual-agent group was 70% more likely to experience major bleeding, there was no significant difference in intracranial or fatal bleeding. Experts think the results will be practice changing.

Tone down

If you recognize canakinumab (Ilaris) from its rare use in juvenile idiopathic arthritis than you're smarter than us. The IL-1ß inhibitor, a profound blocker of immune-driven inflammation, was found to cut the rate of recurrent myocardial infarction (MI) or stroke by 15% vs placebo over 4-year follow-up in patients with prior MI and high C-reactive protein in the 10,000 patient CANTOS trial. The trial is the first proof that directly targeting inflammation – rather than lipids – can reduce heart disease. An unexpected increase in fatal infections in the canakinumab treatment group will need further investigation.

Get personal

Sometimes your most accomplished attendings lack a personal touch, so a little hard data can help guide them. The TROPICAL-ACS trial randomized 2,600 patients undergoing percutaneous coronary intervention (PCI) to receive 12 months of prasugrel (a strong anti-platelet agent) vs. 1 week of prasugrel followed by rapid de-escalation to clopidogrel (a weaker anti-platelet agent) if platelet function testing found no evidence of highly reactive platelets. Bleeding events and cardiovascular outcomes were similar in both groups. The results introduce individualized medicine to the post-PCI setting, and may allow for less potent platelet inhibition in many patients.

Say it on rounds

When you can't keep your hands off the free breakfast bagels

A carb-controlled diet may be best for everyone, not just your diabetics. The PURE study examined macronutrient intake and overall mortality in 130,000 participants in 18 countries. High carbohydrate intake was linked to higher overall mortality and non-cardiovascular mortality, while high fat and protein intake were associated with improved long-term outcomes. Despite the ubiquity of gross non-fat snacks in your childhood lunchbox, fat intake held no association with cardiovascular disease.

When your attending asks for an endoscopy along with a whole body MRI

There are limits (we think), but a survey questionnaire of over 2,000 physicians blamed overtreatment on fear of malpractice, patient pressure, and difficulty accessing medical records. Surveyed docs thought that about 20% of medical care was unnecessary, including about 11% of procedures. And while overtreatment was pinned largely on external factors, doctors did admit that overtreatment was much more likely when physicians were in line to profit from tests and procedures.
PLoS One

Brush up

Snooze cruise

Nodding off in noon conference is more a sign of boredom than obstructive sleep apnea (OSA), but consider the disorder in all patients with excessive daytime sleepiness. The disease is under-recognized and much of the burden of diagnosis falls on primary care physicians. Use the STOP-BANG questionnaire, which is highly sensitive for moderate and severe disease, as a screening tool in patients with suspicious symptoms. Comprehensive polysomnography testing can establish the diagnosis, though the use of portable monitoring systems is increasingly common.

Get meta

With sleep apnea and cognition. An analysis of 14 studies with over 4 million combined patients found that sleep disordered breathing (SBD) was associated with a 26% increased risk of developing cognitive impairment. While the underlying mechanism is unclear, hypoxia-induced vascular dysfunction, neuronal damage, and blood-brain barrier disruption are thought to alter cerebral plasticity. Those with SBD also had slightly worse executive function, though memory and global cognition remained intact.

What your tech friends are talking about

With your handwriting getting worse and worse with each year of medical training, new uses for pens – like detecting cancer in tumor margins on the operating table – seem more relevant than ever. An animated video has more.

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