Nov 4, 2016

CABG patch, stent garden

The story

When your pipes are blocked, you use a plunger. But life is trickier for cardiologists and their patients with coronary artery disease (CAD). Two new trials compare stents with surgery in left main CAD.

The background

Guidelines recommend coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) for multivessel CAD and left main CAD. Smaller trials, combined with improved drug-eluting stent technology, have led to the emergence of PCI as an alternative therapy for left main lesions. 

The trials

The 1,900 patient EXCEL trial (NEJM) compared PCI to CABG in unprotected left main disease and found similar rates of death, stroke, and myocardial infarction (MI) at 3-year follow-up. In contrast, the 1,200 patient NOBLE trial (Lancet) found significantly fewer subsequent MIs and repeat revascularizations in CABG patients over 5-year follow-up. Overall, CABG patients in the two trials trended towards better long-term outcomes but had more peri-procedural risk, while PCI patients had shorter hospital stays but were more likely to need additional intervention. Here's a detailed guide to trial differences.

The takeaway

PCI and CABG are both reasonable choices for unprotected left main CAD at experienced centers, though the data suggests young patients who are good surgical candidates may be better off with CABG. The similar outcomes between interventions opens up a role for patient preferences in treatment.

Say it on rounds

When you just can't tell if you paged the right person

Life in the hospital is all about uncertainty, and the use of steroids in sepsis is always a bit unclear. The 400 patient HYPRESS trial looked at whether early use of corticosteroids in patients with severe sepsis – where immune system dysregulation accompanies the body's response to overwhelming infection – reduced progression to septic shock. Infusion of hydrocortisone did not change progression to shock, mechanical ventilation, or length of stay in the ICU.

When rounds last longer than your Instagram feed

Scroll down to refresh, and consider that social media may be as good for longevity as it is bad for your attention span. A California group looked at the Facebook activity of 12 million people aged 21 to 65 and found that Facebook users had a 12% lower mortality risk than their offline counterparts. The benefit was largest in those who received the most friend requests, rather than those who initiated requests or posted photos or status updates. People with larger social networks have been shown to live longer, and the authors theorize that an active online social life can complement real-world interactions.

When you whip out your video camera at the intern dance party

Some things weren't meant to be taped. But for the diagnosis of active lesions in Crohn's disease, video capsule endoscopy might be the right choice. A prospective multicenter feasibility study found that diagnostic yields for pan-enteric video capsule endoscopy were higher than those for ileo-colonoscopy in patients with active Crohn's. The study results are preliminary, and more work will need to be done to confirm findings.
Gastrointest Endosc

Brush up

Statins and cholesterol

2013's ACC/AHA guidelines recommend choosing statin therapy for patients aged 40 - 75 without known cardiovascular disease (CVD) based on estimated CVD risk. For all diabetic patients, start with a moderate intensity statin and progress to a high intensity statin if 10-year ASCVD risk score is > 7.5%. For patients without diabetes, start a moderate to high intensity statin in those with scores > 7.5% and consider starting treatment in those with scores between 5% and 7.5%.

What's the evidence

For PCSK9 inhibitors in hyperlipidemia? The PCSK9 enzyme destroys LDL receptors, so inhibitors lead to more circulating receptors and less circulating cholesterol. The 2015 ODYSSEY trial found that the PCSK9 inhibitor alirocumab reduced LDL cholesterol by 62% in patients with confirmed heterozygous familial hypercholesterolemia, coronary disease, or a coronary disease equivalent. The alirocumab group benefitted from a 2% absolute risk reduction in major cardiovascular events over the 78-week follow-up period. 

What your family planning friends are talking about

Mood changes, depression, swings in libido. Men who took a new injectable birth control couldn't handle the side effects, and a trial of the medication was stopped early. Some counter that women have lived with similar birth control problems for decades.

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