Guideline Critics Shift Attacks From Beta Blockers To Statins Reply

With the release today of updated European and US guidelines the ongoing controversy regarding beta-blockers appears to be resolved. But that doesn’t necessarily mean there will be an outbreak of guideline peace and harmony. The critics who helped ignite the controversy over beta blockers now say new statin recommendations contained in the guidelines are based on deeply flawed evidence.

Both the new European and US guidelines say that preoperative initiation of statin therapy may be considered in patients undergoing vascular surgery and that people already taking statins should continue taking them. Now some of the same critics who attacked the reliability of the beta blocker guideline say that this recommendation is not supported by the evidence.

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Tooth Extraction Prior to Cardiac Surgery May Not Be a Good Idea Reply

People with an infected or abscessed tooth are at elevated risk for cardiovascular disease. They are at particular risk for developing a serious infection during surgery, including endocarditis, a potentially life-threatening infection of the heart. Because of this risk, in order to reduce the chance of infection, many patients undergo dental extraction prior to having a planned cardiac surgery. Now, however, a new paper published in The Annals of Thoracic Surgery raises the possibility that prophylactic dental extraction may be far more risky than previously thought.

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FDA Approves Abbot’s MitraClip For Patients At Prohibitive Surgical Risk Reply

The FDA today approved Abbott’s catheter-based MitraClip device for patients with significant symptomatic degenerative MR who are at prohibitive risk for mitral valve surgery. The company said it would launch the device immediately in the United States. The device is the first percutaneous nonsurgical therapy approved for the treatment of mitral valve disease.

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Mitraclip

 

Surgery Preferable To Stents In Elderly People With Carotid Disease Reply

Age should play an important role in choosing a revascularization procedure for people with blocked carotid arteries, according to a new paper published in JAMA Surgery.  Carotid endarterectomy surgery (CEA) is preferable to carotid artery stenting (CAS) in elderly people; for younger patients the two revascularization procedures are broadly similar.

George Antoniou and colleagues analyzed data from 44 studies containing more than half a million CEA and 75,000 CAS procedures. In the CAS group, when compared to younger patients elderly patients were at increased risk for stroke (odds ratio 1.56,CI 1.40-1.75). In the CEA group the stroke results were “equivalent” in the older and younger groups (OR 0.94, CI 0.88-0.99). In the CEA group there was a small but statistically significant increase in the mortality rate in the older group compared with the younger group (0.5% versus 0.4%, OR 1.62, CI 1.47-1.77). No significant difference in mortality between the older and younger groups emerged in the CAS group. In both the CAS and the CEA groups, increased age was associated with a greater risk of adverse cardiac events.

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Study Supports Loosening Guidelines for Surgery After Stent Implantation Reply

According to current guidelines, noncardiac surgery should be delayed for six weeks after bare-metal stent (BMS) implantation and for one year after drug-eluting stent (DES) implantation, though there is little good evidence to support these recommendations. Stent thrombosis caused by discontinuation of antiplatelet therapy in order to lower the risk of bleeding during surgery is the biggest concern. Now, a new study published in JAMA suggests that the guidelines may be over strict and that delays recommended after DES implantation are longer than warranted.

Mary T. Hawn and colleagues analyzed data from nearly 125,000 VA patients who received a stent between 2000 and 2010. Within this group more than 28,000 (22.5%) had a noncardiac operation within 2 years…

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Can Inflating A Blood Pressure Cuff Improve Outcomes Following Bypass Surgery? Reply

http://www.forbes.com/sites/larryhusten/2013/08/15/can-inflating-a-blood-pressure-cuff-improve-outcomes-following-bypass-surgery/

 

For several decades cardiologists have been intrigued by the concept of ischemic preconditioning. A small body of research has consistently found that brief episodes of ischemia (in which reduced blood flow results in damage to tissue) appeared to somehow prepare the body to better handle a major episode of ischemia. Now a new study from Germany published in the Lancet holds out the promise that deliberate ischemic preconditioning prior to bypass surgery might prevent ischemic injury caused by the surgery and may even improve long-term survival. But the investigators themselves say that the results need to be confirmed in a larger study.

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Study Suggests Benefit For Beta Blockers During Noncardiac Surgery Reply

The use of perioperative beta-blockade for noncardiac surgery has been declining as a result of the controversial POISE study, which turned up evidence for harm associated with extended-release metoprolol in this setting. Now a large new observational study published in JAMA offers a contrary perspective by suggesting that perioperative beta-blockade may be beneficial in low- to intermediate-risk patients. But without better evidence the debate about this topic is unlikely to be resolved.

Martin London and colleagues performed a retrospective analysis of 136,745 patients who underwent noncardiac surgery at VA hospitals, 40% of whom received beta-blockade.

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Are Most People With Complex Coronary Disease Getting The Best Treatment? 1

angiogram

The relative value of PCI (stents) and bypass surgery for the treatment of people with blocked coronary arteries has been a topic of intense interest and debate for more than a generation now. Over time, the less invasive and more patient-friendly (and less scary) PCI has become the more popular procedure, but the surgeons (who perform bypass surgery) and cardiologists (who perform the less invasive PCI) have argued furiously about which procedure is safest and will deliver the most benefit in specific patient populations. In general, the most complex cases require the more thorough revascularization provided by surgery, while the more simple cases do well with PCI and can therefore avoid the trauma of surgery. But the specific criteria have remained murky, and interventional cardiologists have aggressively sought to take on increasingly more complex cases.

Now, long term results from a highly influential trial comparing the two procedures offer what is likely the most definitive solution we are likely to have for a very long time. Five year results from the SYNTAX trial have now been published in the Lancet.

Here’s some of the perspective on this study from two very savvy cardiologists, Rick Lange and L. David Hillis. (These comments are extracted from their original publication in CardioExchange. Note that I work on CardioExchange, which is published by the New England Journal of Medicine.)

…The “bottom line” conclusions are:

  1. CABG should remain the standard of care for patients with complex lesions…
  2. For patients with 3-vessel disease considered to be less complex… PCI is an acceptable alternative.
  3. All the data from patients with complex multivessel CAD should be reviewed and discussed by a cardiac surgeon and an interventional cardiologist, after which consensus on optimal treatment can be reached.

But Lange and Hillis, while they seem to largely agree with the study findings, also cast doubt on whether most physicians are likely to pay attention to the study details. They wonder whether most hospitals actually live up to the standards in the study, which requires, for each patient, a review of each patient by the multidisciplinary heart team, and the calculation of a complex SYNTAX score to establish the precise degree of risk.

Okay, let’s be honest….

  1. In your hospital, in what percentage of patients with left main or 3 vessel CAD are all the data systematically reviewed and discussed by a “Heart Team”?
  2. Do you calculate SYNTAX on all patients with left main or 3 vessel disease, or do you usually just “guestimate” lesion complexity?

If Lange and Hillis’s suspicions are correct, many people with complex coronary lesions are not receiving the best possible care. Hmmm.

The Best Doctor Blog On The Internet 1

Let me say it right away: the best blog written by a doctor, at least that I’ve ever read, is by a provincial South African general surgeon who calls himself Bongi. He doesn’t write about complex medical policy, and he doesn’t worry too much about appropriate use criteria or whether a patient who needs anticoagulation should get warfarin or Xarelto. Instead, he writes about his astonishing experiences as a front-line surgeon (and, for many years, as a medical trainee) in a country on the border between first and third world medicine.

His stories will blow your head off. One minute you’ll be laughing. The guy is seriously funny, possessing a keen sarcastic wit with an edgy South African accent. But then, suddenly, just when you’re enjoying the antics of his colleagues and countrymen,he’ll turn deadly serious, and leave you breathless or in tears.

Read the rest of this post on Forbes.