Guest Post: Running on empty Reply

Editor’s Note: The following post was written by Westby G. Fisher, an electrophysiologist  practicing at NorthShore University HealthSystem in Evanston, IL and  a Clinical Associate Professor of Medicine at the University of Chicago’s Pritzker School of Medicine. He is  the author of Dr Wes, a widely known and highly admired blog about cardiology, the internet, and anything else that catches his imagination.

“In sixty-nine I was twenty-one and I called the road my own
I don’t know when that road turned onto the road I’m on.

Running on, running on empty
Running on, running blind
Running on, running into the sun
But I’m running behind.”

-Jackson Browne

“We’re stretch so thin, right now. No new hires in sight. Look at this list of patients: twenty-two of ’em, all over 70, eight “new’s” among them, every one with tons of medical issues. Didn’t get out of here until 10:30 last night. Then back at it at 8 (am) this morning. I’m telling you, I hate it. Hate it. There just doesn’t ever seem to be an end in sight. We’re just a bunch of “f**in’ employees, and no one gives a damn.”

I sat stunned. I knew him from before. His job had taken it’s toll. This wasn’t the guy I knew earlier. I really didn’t know how to respond, but did suggest that maybe hospitalist medicine wasn’t for him.
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NEJM: trials find few long term benefits for endovascular AAA repair Reply

The short-term benefits of endovascular abdominal aortic aneurysm repair seen in previous trials appear to evaporate with long-term followup, according to results of two large trials published online in the New England Journal of Medicine.

In EVAR 1 (United Kingdom Endovascular Aneurysm Repair 1), between 1999 and 2004, 1,252 patients with large abdominal aortic aneurysms were randomized to either endovascular or open repair. As seen in previous trials, the early results appeared to favor endovascular repair: at 30 days the operative mortality was 1.8% in the endovascular-repair group versus 4.3% in the open-repair group.
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More pieces of the Multaq puzzle 6

I don’t want to keep harping on Multaq (see the bottom of this post for links to recent stories), but then I keep running across promotions for so-called educational programs that practically beg to be scrutinized. Earlier today I received an email from theheart.org CME Center. At the top of the message was this featured CME program:

Reducing Hospitalizations in Atrial Fibrillation: Optimizing Arrhythmia Control
The purpose of this activity is to educate clinicians on strategies for switching AADs and the impact of AF recurrences on hospitalization.

Not mentioned in the email was the sponsor of the program, but it probably won’t come as a big surprise to learn that it was Sanofi Aventis. I took a quick look at the transcript of the program, which appeared to be essentially a detailed list of excuses and reasons to switch AF patients from amiodarone or other drugs to dronedarone. The heavy lifting was performed mostly by one of the participants, Peter Kowey. Here’s part of his conclusion:
Click to continue reading…

Survival after CABG “isn’t about skin color or gender, it’s about being poor” 2

“We were surprised that consistently and pervasively, through every way of looking at the data, it turns out this isn’t about skin color or gender. It’s about being poor.” So said Colleen Koch, in a press release from the AHA, about her study in Circulation: Cardiovascular Quality and Outcomes. Along with her colleagues, Koch followed more than 23,000 patients who had CABG between 1995 and 2005. They found that lower socioeconomic position (SEP) was associated with reduced survival after surgery; after adjusting for SEP race and gender were no longer significant. As the investigators expected, blacks and women had lower SEP compared to whites and men.
Click to read the AHA press release…

Experts disagree on when to use dronedarone (Multaq) 3

The billion dollar question is this: when to use Multaq (dronedarone)? A new viewpoint and commentary in JACC from Sanjay Kaul’s group (Singh et al) offers a highly conservative answer to the question. An accompanying editorial by Christian Torp-Pedersen, Ole Dyg Pedersen, and Lars Køber provides a much more liberal view of the drug.

It all comes down to different ways of interpreting the safety and efficacy data. Surprisingly, both groups agree that dronedarone is less effective than amiodarone as an antiarrhythmic drug, and both agree that dronedarone is safer than amiodarone in the indicated population of low and intermediate risk patients. And both agree that dronedarone should not be used in high risk patients (unstable NYHA class 3 and class 4 HF patients).
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Guest Post: The iPad goes live at BIDMC Reply

Editor’s Note: This post originally appeared on Dr. John Halamka’s  Life as a Healthcare CIO blog. It is written by Dr. Larry Nathanson, who leads the Emergency Medicine Informatics efforts at Beth Israel Deaconess Medical Center. (Note that the photo contains only fictitious patient names.) One further note: I believe that it is a distinct probability that the iPad is going to dramatically alter the manner in which many of us find, consume and share all kinds of information and media. I’m sure that there are many of you out there who are skeptical of this view. On the chance that I’m right, the following post provides a fascinating glimpse at one possible use of the iPad in a medical setting.

I had been anxiously awaiting the arrival of my iPad –This is the form factor I have been asking (begging) of all the vendors for years. I’m very happy to say that it appears to be living up to my high expectations.
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Waiting for IMPROVE-IT… Reply

Last week the IMPROVE-IT investigators, led by Rob Califf, provided an update on the trial’s progress in the American Heart Journal. Remember: this is the trial that everyone hopes will finally resolve the question of ezetimibe’s clinical value. (Earlier this year, as we reported, Merck announced several of the details contained in this paper.)

According to Califf et al, IMPROVE-IT will now most likely enroll the last of its 18,000 subjects in June of this year.  They project the trial will then reach completion in June 2013, when all patients have been followed for at least 2.5 years and when 5,250 primary end points will have been reached. In addition, the investigators have added an additional interim analysis when 75% of events have occurred (in addition to the previously planned analysis at 50%).
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Prystowsky lecture resurfaces, this time with COI disclosures 3

It’s back. This time with a disclosure of conflicts of interest. The Eric Prystowsky lecture that was the only piece of original content on AFibProfessional.org, the Sanofi-sponsored website run under the auspices of the ACC and HRS, is back on the site once again after being removed last week after a critical story was published here on CardioBrief. (Click here and here to read the full stories from last week).

Here’s what Prystowsky disclosed:
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New York Times: broader indication for rosuvastatin once again raises risk vs benefit in healthy population 2

Statins may not be as safe as many people think, and the recently granted expanded indication for rosuvastatin may create new problems while providing few benefits, according to an article in the New York Times by Duff Wilson. The Times article places before the wider public the ongoing debate that has been taking place in cardiology circles since the presentation of the JUPITER results. (For just one example, see this earlier CardioBrief story.)

Wilson focuses on the issue surrounding primary prevention: “But for healthy people who would take statins largely as prevention — which would be the case for the new category of Crestor patients — other experts suggest the benefits may not outweigh any side effects.” He quotes Mark Hlatky: “It’s a good thing to be skeptical about whether there may be long-term harm from healthy people taking a drug like this.”
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UK’s NICE plays a bit nicer with Multaq (dronedarone) Reply

The UK’s NICE (National Institute for Health and Clinical Excellence) has eased up a bit on its preliminary recommendations for dronedarone (Multaq). It had previously recommended that the drug not be used to treat atrial fibrillation. The revised draft guidance recommends use of dronedarone in people with AF uncontrolled by first-line therapy (usually including beta-blockers) and who have additional cardiovascular risk factors and who do not have unstable NYHA class III or IV heart failure. The appraisal committee will accept new comments until April 22, prior to a committee meeting on May 26. The final appraisal is expected this summer.
Click to continue reading, including press releases from NICE and Sanofi…

SEC and DOJ looking into Boston Scientific ICD recall 2

There’s more fallout from the Boston Scientific ICD recall. The US Department of Justice has sent a subpoena to the company and the SEC is looking into the matter as well, according to a report by Jonathan Rockoff in the Wall Street Journal.

Yesterday Boston Scientific released the transcript of a conference call with physicians about the recall in which the company confirmed details about the cause of the recall, which Wall Street analysts had already largely figured out. The company has filed a request for approval within 30 days for the manufacturing changes that sparked the recall, but it is possible that the FDA will take as much as 135 days for its review before giving Boston Scientific the green light to resume ICD sales.

FDA delays approval of Certriad (rosuvastatin/fenofibric acid combo) 1

Abbott and AstraZeneca today announced receipt from the FDA of a complete response letter (CRL) for Certriad, their combination of Abbott’s TriLipix (fenofibric acid) and AstraZeneca’s Crestor (rosuvastatin). The companies did not provide details on the contents of the letter, but Wall Street analysts are predicting that the CRL means that Certriad’s approval will be, at best, delayed until next year. The letter follows by a few weeks the presentation at the ACC of the ACCORD trial results, which found no benefit for the combination of simvastatin and fenofibric acid over simvastatin alone in type 2 diabetics.
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Archimedes (the computer model, not the Greek) supports screening for diabetes Reply

Screening for type 2 diabetes may be cost effective if it is initiated between the ages of 30 and  45 and repeated every 3-5 years, according to Archimedes, a sophisticated computer modelling program (and not the ancient Greek scientist).

Richard Kahn and colleagues (including David Eddy, the subject of a recent article in Wired magazine) used Archimedes to evaluate the value of 8 screening strategies for type 2 diabetes. The authors reported that screening strategies would result in reductions in MI  and microvascular events (for each, 3-9 events would be prevented per 1000 people screened) and would increase the number of quality-adjusted life-years over 50 years. There was little or no effect on stroke incidence.
Click to continue reading, including an interview with Richard Kahn…

More Multaq: Prystowsky whack-a-mole, ACC responds, Sanofi overtures to EPs 8

In response to yesterday’s posting about several problems involving a supposedly independent ACC/HRS website (AFibProfessional.org) supported by Sanofi-Aventis, the manufacturer of Multaq (dronedarone), several new events have transpired:

Prystowsky Whack-a-Mole– The Eric Prystowsky lecture has been removed from AFibProfessional.org. An ACC spokesperson told CardioBrief that the ACC, in conjunction with its partner, HRS,  was “taking some immediate steps to address the issue that has been raised.” (By way of background, the off-label, off-guideline Prystowsky lecture was the only original content on the site, and there had been no disclosure that Prystowsky had received compensation for Sanofi.)

Update, Wednesday, March 31 An alert reader has pointed out that the Prystowsky lecture has now reappeared on the site, this time accompanied by conflict of interest disclosures.

Click to continue reading…

WTF? Now you can diagnose your own heart attack right at home Reply

Great news for hypochondriacs: you no longer have to go to the ER or see a doctor to find out if you are having a heart attack– at least if you live in Europe. Now you can do it from the comfort of your own home. A Chinese company announced that its consumer test for MI had received CE certification in Europe. Here is a summary of the product from Medgadget:
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Pieces of a puzzle: Multaq, Sanofi, ACC, HRS, Prystowsky, AF Guidelines 10

CardioBrief today dispenses with its usual format. Our post today is a puzzle. Here are the various pieces of the puzzle:

Puzzle Piece 1: The commercial prospects of Multaq (dronedarone) appear increasingly cloudy, according to a news report by Jim Edwards on bnet.com. Wall Street estimates for the drug, which some had thought might reach € 3 billion, have been drastically reduced, with at least one analyst stating it will never sell more than €300 million a year for its maker, Sanofi-Aventis.

Puzzle Piece 2: The ACC and the Heart Rhythm Society (HRS) have jointly launched AFibProfessional.org, which they define as “a unique collaboration to address atrial fibrillation for the cardiology community.” The Sanofi logo appears in the lower right hand corner under “site sponsors” (no other companies are listed). There is no mention of sponsorship, or the role of the sponsor, anywhere else in the site that I can find.

Puzzle Piece 3: As far as I can tell, with one exception all the educational content on the site is drawn from material previously available on the HRS site and the ACC’s CardioSource. Here’s the exception:
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Avandia again: Nissen and JAMA editors spin RECORD round and round 3

Avandia is back in the news. After a month of relative silence, following the New York Times disclosure of FDA and Senate reports critical of rosiglitazone, the subsequent release of the Senate report, and the revelation that Steve Nissen had secretly recorded a meeting with GSK executives (though the significance of this last event is unclear), a new JAMA commentary by Steve Nissen and an accompanying editorial by JAMA’s editors will surely add new fuel to the Avandia bonfire.
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Why is there a red dress on diet Coke cans? 9

I have a question for the NHLBI: why is there a red dress on diet Coke cans? But before raising the question, let’s step back for a moment. Last Tuesday at the ACC Bob Harrington and Steve Nissen debated each other (and, occasionally, the audience) over the subject of conflicts of interest in medicine. The debate was widely covered by the Associated PressForbes, the Wall Street Journal Health Blog, and MedPage Today (where you can also find a link to listen to the initial presentations of the debaters).

The debate was combative but thoughtful and even nuanced– among other things, Harrington conceded that there have been many egregious cases of conflict of interest and Nissen acknowledged that academics need to work with industry. But after the debate almost the only thing reporters and others who were in the audience focused on was a Nissen blooper, which happened when Nissen criticized the AHA for issuing a statement some time ago that pointed out the limitations of a study linking soda consumption to metabolic syndrome. Nissen said the AHA had compromised itself by accepting money from Coca-Cola. To illustrate his point he showed images of Diet Coke cans with red dresses and hearts.

Turns out Nissen made a mistake. The AHA does not have a deal with Coke. But here’s where it gets weird: the NHLBI has its own Women’s Heart Health red dress program, and it does have some kind of deal with Coke. Who knew there were two such programs? And who would ever have thought Coke could buy a partnership with the NHLBI?
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FDA panel recommends approval of Medtronic’s MRI-safe pacemaker Reply

The FDA Circulatory System Devices Panel unanimously voted to recommend approval of Medtronic’s  REVO MRI SureScan Pacing System, the first MRI-safe pacing system. The panel said the company should be required to perform a post-approval study. In addition, they requested that the label prominently note that the device should only be used with leads that have been tested with the device.
Click for links to news reports and a Medtronic press release…

FDA panel supports expanded indication for CRT-Ds Reply

The FDA Circulatory System Devices Panel voted unanimously in favor of an expanded indication for Boston Scientific’s CRT-D devices based on the MADIT-CRT study. The panel stipulated that the expanded indication should be limited to NYHA Class I and II patients with LBBB, LVEF ≤ 30% and QRS duration ≥ 130ms. The panel also stipulated that the company should be required to design a postmarketing study in consultation with the FDA.

Click for links to media coverage and a press release from Boston Scientific…