CLL review

From Mayo Clinic Proceedings.

Are beta blockers really cardioprotective?

From the results of a large prospective cohort study:

Objective

To assess the relationship between use of β-blockers and all-cause mortality in patients with and without diabetes.

Patients and Methods

Using data from the US National Health and Nutrition Examination Survey 1999-2010, we conducted a prospective cohort study. The study participants were followed-up from the survey participation date until December 31, 2011. We used a Cox proportional hazards model for all-cause mortality analysis. The multivariate-adjusted hazard ratios (HRs) of the participants taking β-blockers were compared with those of the participants not taking β-blockers.

Results

This study included 2840 diabetic participants and 14,684 nondiabetic participants. Compared with diabetic participants not taking a β-blocker, all-cause mortality was significantly higher in diabetic participants taking any β-blocker (HR, 1.49; 95% CI, 1.09-2.04; P=.01), taking a β1-selective β-blocker (HR, 1.60; 95% CI, 1.13-2.24; P=.007), or taking a specific β-blocker (bisoprolol, metoprolol, and carvedilol) (HR, 1.55; 95% CI, 1.09-2.21; P=.01). In addition, all-cause mortality in diabetic participants with coronary heart disease (CHD) was significantly higher in those taking beta-blockers, compared with those not taking beta-blockers (HR, 1.64; 95% CI, 1.08-2.48; P=.02), whereas that in non-diabetic participants with CHD was significantly lower in those taking beta-blockers (HR, 0.68; 95% CI, 0.50-0.94; P=.02). A propensity score–matched Cox proportional hazards model yielded similar results.

Conclusion

Use of β-blockers may be associated with an increased risk of mortality for patients with diabetes and among the subset who have CHD.

An editorial in the same issue provided a nice perspective on the overall issue of cardioprotection attributed to beta blockers.

Several important points can be made:

The idea of cardioprotective beta blockers came from trials in post MI patients, done decades ago, showing reduced mortality attributable to beta blockers.

Those trials were conducted in the pre-reperfusion era and thus tended to involve patients with chronically occluded arteries and larger infarcts with significant scars. This represents a substantially different population compared to the post MI patients we treat today.

The idea of cardioprotective beta blockers was inappropriately extrapolated to areas of cardiovascular medicine outside these clinical trials.

The editorial concludes:

..the only ironclad indication for cardioprotection with β-blockers remains heart failure with reduced ejection fraction,11, 12 the very indication that decades ago was the only contraindication for β-blocker therapy.4

Caffeine intake associated with reduced vascular stiffness

Findings here.

Related editorial here.

Tell me something I didn’t know: More expensive care isn’t necessarily better care

A JAMA Internal Medicine study.

An ABIM leader enters the debate over MOC

Defenders of the board certification establishment have been largely silent amidst the onslaught of criticism so it’s noteworthy when one of the speaks out. Here’s a viewpoint piece in JAMA. Heavy on unfounded assumptions, light on evidence,  unconvincing to me.

MOC or Drexit?

An interesting read at Kevin MD.

MINOCA: it’s definitely a thing

MINOCA (myocardial infarction with non obstructed coronary arteries) has been known for quite some time but is greatly under appreciated. Such patients meet the universal definition of MI but have coronary arteriograms demonstrating no lesions causing greater than 50% obstruction. They may be deceptively labeled as having “insignificant coronary artery disease.” Some will be misdiagnosed as stress cardiomyopathy (formerly Takotsubo) or myocarditis. What’s really going on? It’s a complex and poorly understood interplay of multiple factors. Mild (less than 50% obstructive) plaques may ulcerate or rupture. This may cause thrombus with obstruction which spontaneously recanalizes. Inflammation, endothelial dysfunction, coronary spasm and procoagulant influences may interact. Other patients may have type 2 MI. These mechanisms are reviewed in a recent editorial.

Mind what you eat and lose weight

Benefits of mindful eating.

Can midodrine help patients get off IV pressors faster?

A preliminary study suggests it can and a randomized clinical trial is in progress.

Microscopic colitis

Here is a free full text review.

From the review:

Microscopic colitis (MC), which is comprised of lymphocytic colitis and collagenous colitis, is a clinicopathological diagnosis that is commonly encountered in clinical practice during the evaluation and management of chronic diarrhea. With an incidence approaching the incidence of inflammatory bowel disease, physician awareness is necessary, as diagnostic delays result in a poor quality of life and increased health care costs. The physician faces multiple challenges in the diagnosis and management of MC, as these patients frequently relapse after successful treatment. This review article outlines the risk factors associated with MC, the clinical presentation, diagnosis and histologic findings, as well as a proposed treatment algorithm. Prospective studies are required to better understand the natural history and to develop validated histologic endpoints that may be used as end points in future clinical trials and serve to guide patient management.

Medical errors in nursing home patients

From a systematic review:

Medication errors (MEs) result in preventable harm to nursing home (NH) residents and pose a significant financial burden. Institutionalized older people are particularly vulnerable because of various organizational and individual factors. This systematic review reports the prevalence of MEs leading to hospitalization and death in NH residents and the factors associated with risk of death and hospitalization. A systematic search was conducted of the relevant peer-reviewed research published between January 1, 2000, and October 1, 2015, in English, French, German, or Spanish examining serious outcomes of MEs in NHs residents. Eleven studies met the inclusion criteria and examined three types of MEs: all MEs (n = 5), transfer-related MEs (n = 5), and potentially inappropriate medications (PIMs) (n = 1). MEs were common, involving 16–27% of residents in studies examining all types of MEs and 13–31% of residents in studies examining transfer-related MEs, and 75% of residents were prescribed at least one PIM. That said, serious effects of MEs were surprisingly low and were reported in only a small proportion of errors (0–1% of MEs), with death being rare. Whether MEs resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems.

Update on hypertrophic cardiomyopathy

Form a recent review:

Most clinicians would recommend ICD therapy if any one of the five major risk factors is present, although recent debate has focused on whether at least two risk factors are required…

Previous cardiac arrest/ventricular tachycardia (secondary prevention)

Family history of premature sudden cardiac death

Left ventricular wall thickness greater than or equal to 30 mm

Previous episodes of documented NSVT (greater than or equal to 3 beats, rate greater than or equal to 120 bpm)

Unexplained syncope

Concerning treatment in general:

Many treatment options are currently available for HCM patients. This ranges from no treatment; lifestyle modifications, e.g. avoiding competitive sports in all patients with HCM; use of pharmacological agents e.g. beta blockers, calcium channel blockers, and diuretics; to surgical septal myectomy and transcoronary alcohol septal ablation of the myocardium (i.e. the creation of a limited septal infarct by direct injection of alcohol into a septal perforator artery) for individuals with significant left ventricular outflow tract obstruction with symptoms unresponsive to drug therapy. The single most important advance in the clinical management of HCM has involved the use of ICD therapy in the prevention of sudden death [12] . Recent studies indicate that treatment of individuals at highest risk of sudden death with an ICD is the most definitive form of therapy in preventing sudden death and easily surpasses empirically-based preventative strategies previously used in HCM, e.g. amiodarone and beta blockers.

Improved understanding of bicuspid aortic valve disease

A recent article cites findings coming out of the newly established International Bicuspid Aortic Valve Disease Registry.

New guidelines for ECG interpretation in athletes

Reviewed here.

Great info if you can access it. Unfortunately it is behind a pay wall and the graphics and text are too complicated for me to give key points here.

Don’t conflate type 2 MI and NSTEMI!

Confusion remains wide spread despite the publication of this distinction years ago. But now, according to this piece in Circulation, the coding world is finally catching up. ICD 10 now has a code for type 2 MI. Here are some of my take home points:

A type 2 MI is not an acute coronary syndrome.

On initial presentation the distinction is based on clinical circumstances and may occasionally be difficult.

Further investigation usually makes the distinction clear by the end of the hospitalization.

Type 2 MI, though a distinct category, is not a primary single entity in that it is always secondary to something else, one or more of many known conditions. For this reason it is heterogeneous and there are no guidelines for type 2 MI per se. Its treatment always consists of management of the underlying conditions that are altering the myocardial oxygen supply demand balance.

Though ICD 10 now recognizes the distinction, type 2 MI has yet to be excluded from certain performance and regulatory categories for MI due to acute coronary syndrome.

Those who conflate NSTEMI and type 2 MI not only expose their ignorance (or disregard) of the classification and pathophysiology of MI but also risk subjecting patients to inappropriate and potentially harmful treatments. An example is provided in the article.

Metformin monotherapy versus dual therapy with the addition of a sodium glucose co-transporter 2 inhibitor (SGLT-2)

From a recent systematic review:

Highlights

•Type 2 Diabetes Mellitus (T2DM) is a current global threat.

•Sodium-glucose co-transporter 2 inhibitor is a new approach for T2DM management.

•Combined therapy of SGLT2 inhibitor and metformin is more effective.

Abstract

Background

Type 2 Diabetes Mellitus (T2DM) is a chronic disorder and its treatment with only metformin often does not provide optimum glycemic control. Addition of sodium glucose cotransporter 2 inhibitor (SGLT2) will improve the glycemic control in patients on metformin alone. In this study, an attempt is made to investigate the combined therapy of SGLT-2 with metformin in managing T2DM in terms of lowering HbA1c and body weight and monotherapy using metformin alone in HbA1c and body weight reduction.

Objectives

To compare the clinical effectiveness of combined therapy using SGLT2 inhibitor and metformin with monotherapy using metformin alone in HbA1c and body weight reduction.

Method

A systematic review of the randomized controlled trials has been carried out and Cochrane risk of bias tool was used for the quality assessment. Patient, Intervention, Comparison and Outcomes (PICO) technique is used to select the relevant articles to meet the objective.

Results

The studies used in this article are multicenter, double-blinded randomized controlled trials on SGLT2 inhibitors with methformin, there were a total of 3897 participants, with a range of 182 to 1186 individual study size were included. Studies showed that combined therapy were more effective in HbA1c and body weight reduction as compared to monotherapy.

Possible health benefits of dietary magnesium

Report here.

Methamphetamine related heart failure: rising prevalence, distinct phenotype

From the AHA meeting abstracts:

Hypothesis: We hypothesized that in a VA population over a 15 year period, we would observe a rising prevalence of MethHF in admitted patients, along with a unique phenotype.

Methods: Among 9588 patients with diagnosis of heart failure treated at San Diego VA Medical Center in between 2005-2015, 480 were identified to have history of methamphetamine abuse as determined by ICD-9 diagnosis code and/or urine toxicology screen as well as a diagnosis code of heart failure. Demographic, diagnostic, and clinical characteristics of MethHF and heart failure patients without methamphetamine use (HF) were compared. ..

Results: From 2005-2015, the prevalence of methamphetamine usage among patients with heart failure increased linearly (Figure 1). A preliminary cohort comparison demonstrated MethHF had similar ejection fraction and BNP levels but trends toward increased troponin levels, more atrial fibrillation, and a higher GFR. MethHF patients had a greater risk of ER visits (2.3 per year vs 0.5 per year, p=0.01) and a trend towards a greater risk of all-cause hospital readmission...

Metformin use and the risk of B 12 deficiency

From a recent study:

Conclusion

Long-term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Because metformin is first line therapy for type 2 diabetes, clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement.

Metacognition: from study habits to clinical reasoning

This article was published in a pharmaceutical education journal but it has general applicability.